Behavior Change Readiness Assessment Questionnaire Form
Evaluate your readiness for behavior change with this concise assessment. Please answer each question honestly to help identify your current stage and support needs.
How important is it for you to make this change at this time?
*
Not at all important
1
2
3
4
Extremely important
5
1 is Not at all important, 5 is Extremely important
How confident do you feel about your ability to make this change?
*
Not at all confident
1
2
3
4
Extremely confident
5
1 is Not at all confident, 5 is Extremely confident
Which statement best describes your current stage regarding this behavior change?
*
I am not considering change
I am thinking about change
I am preparing to change
I have recently started changing
I have maintained the change
How much support do you feel you have from others for making this change?
*
No support
1
2
3
4
Strong support
5
1 is No support, 5 is Strong support
How ready do you feel to take action in the next 30 days?
*
Not ready
1
2
3
4
Very ready
5
1 is Not ready, 5 is Very ready
What are your main barriers to making this change? (Select all that apply)
*
Lack of time
Lack of motivation
Lack of support
Unclear goals
Other
How often do you think about making this change?
*
Rarely or never
Sometimes
Often
Almost always
Please rate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I believe I can succeed in making this change
1
2
3
4
5
I know the steps I need to take
6
7
8
9
10
I have the resources I need
11
12
13
14
15
I am committed to making this change
16
17
18
19
20
If you have attempted this change before, what was the main reason it was difficult to maintain?
*
Lost motivation
Lack of support
Unrealistic goals
Other priorities
Not applicable
What is one thing that would help you feel more ready to change?
*
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