Online Prevention Plus Wellness Goal Contract

This Goal Contract takes 10-minutes to complete.

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* 1. Are you...

Male

Female

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* 2. How old are you?

12 years old or younger

13 years old

14 years old

15 years old

16 years old

17 years old

18 years old or older

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* 3. What grade are you in?

9th grade

10th grade

11th grade

12th grade

Ungraded or other grade

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* 4. Do you pledge to avoid using alcohol and drugs during the next 7 days in order to maintain an active and healthy lifestyle?

Yes

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* 5. Which one of the following healthy habits will you improve during the next 7 days? Chose one.

Get 8 or more hours sleep each night

Eat a healthy breakfast every day or eat a daily variety of other healthy foods such as fresh fruits and vegetables

Participate in some fun physical activity or sports at least 30 minutes 4-5 days per week

Practice a stress control technique most days a week like yoga, meditation, prayer or walking in nature.

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* 6. List a specific, measurable healthy habit will you improve from the list above. For example, playing tennis is measurable but getting more exercise is not, and eating more fruits and vegetables is measurable but eating healthier is not.

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* 7. List an exact amount of that habit you will do each time. For example, 30 minutes each time, or 5 servings of fruits and vegetables each day.

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* 8. List an exact frequency of the habit you will do. For example, 4 days a week, Monday-Thursday, or each day of the week.

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* 9. In addition to yourself, who else will sign this goal plan to make it an official contract between you and them?

Mom or dad

Grandmother or grandfather

Aunt or uncle

Older brother or sister

Trusted and supportive friend

Other (please specify)

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* 10. Where will you post your goal plan/contract so you can see it every day and be reminded to monitor your health habits? Choose one.

Bedroom wall or mirror

Bathroom mirror

Refrigerator door

TV or computer

Other (please specify)

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* 11. Add your signature and date below.

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* 12. Have your co-signer sign and date below.

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* 13. Congratulations! You have successfully completed the Prevention Plus Wellness Goal Contract. Remember to place this contract where it can be seen each day to monitor your daily goal progress. After one week, review your goal plan and complete another to help you continue to experience success in reaching your goals.

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* 14. You’ve taken the first and most important step toward improving your wellness. Improving yourself is a life-long process. It takes committing to small changes. Focus on and celebrate the small gains you make each day, week and month. You can do it! Keep trying. Never quit!

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* 15. What did you like BEST about the Prevention Plus Wellness lesson? For example, how did it help you with your health habits, motivation, goal setting, self-esteem, etc.

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* 16. What did you like LEAST about the Prevention Plus Wellness lesson? For example, what would you like to see changed or improved?

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* 17. PRINT OUT YOUR COMPLETED GOAL CONTRACT NOW. Then take it to be co-signed and dated by the person you identified above. Now, rate this Goal Contract experience.