Technology Addiction Cessation Log Form
Log your progress and experiences as you work toward reducing or ceasing technology use. Use this form to track each step of your journey.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Technology Behavior Being Tracked
*
Please Select
Social Media
Video Games
Streaming Services
Online Shopping
Web Browsing
Mobile Apps
Other
Date and Time of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Time Spent or Days Since Last Use
*
Triggering Situation
*
Coping Action Taken
*
Craving Intensity
*
None
1
2
3
4
5
6
7
8
9
Very Strong
10
1 is None, 10 is Very Strong
Did a Lapse Occur?
*
Yes
No
If a lapse occurred, briefly describe what happened
Additional Notes or Follow-Up
Submit Log Entry
Should be Empty: