Change Questionnaire
Amanda Brody‚ 2008
Part 1
REASONS FOR WANTING TO MAKE THE CHANGE
1. I feel that I should make this change.
2. People who are important to me want me to make this change.
3. It will be good for my physical health if I make this change.
4. It will be good for my mental or emotional health if I make this change.
5. I will feel better about myself if I make this change.
6. If I make this change‚ I will be able to do things that I’ve wanted to do but I couldn’t do before.
7. If I succeed in making this change‚ it will give me a real sense of accomplishment.
8. Others will think more highly of me if I succeed in making this change.
9. If I make this change‚ I will be able to function better at work or at home.
10. My relationships with friends or family members will benefit if I make this change.
11. Making this change is challenging‚ and I enjoy a good challenge.
12. I want to prove to myself that I am capable of making this change.
13. I want to prove to others that I am capable of making this change.
14. There are opportunities I might miss if I don’t make this change.
15. I can’t feel that good about myself unless I make this change.
16. Others will be disappointed in me if I don’t make this change.
17. Not changing is causing problems for me at home or at work.
18. It will hurt or harm other people if I don’t make this change.
19. I am afraid that something bad will happen to me if I don’t make this change.
Part 2
REASONS FOR NOT WANTING TO MAKE THE CHANGE
1. I feel like there is nothing I can do that will make me change.
2. I don’t think I’ll be able to do the things I need to do in order to make this change.
3. I keep putting off doing the things I need to do in order to make this change.
4. I keep forgetting to do the things I need to do in order to make this change.
5. I don’t know exactly what I need to do in order to make this change.
6. I am too busy to do the things I need to do in order to make this change.
7. I feel like I just can’t get myself to do the things I need to do to make this change.
8. I don’t like admitting to myself that I need to make this change.
9. I don’t like admitting to others that I need to make this change.
10. I don’t feel like doing what I need to do in order to make this change.
11. Although I know I need to make this change‚ sometimes I just don’t want to.
12. I am afraid that I will get upset with myself if I try to make this change and don’t succeed.
13. I am afraid that others will get upset with me if I try to make this change and don’t succeed.
14. I am afraid that I will demand more of myself if I succeed in making this change.
15. I am afraid that others will demand more of me if I succeed in making this change.
16. I don’t want to do things that remind me that I have something I need to change.
17. I think if I did make this change‚ it might have a bad effect on a relationship that is important to me.
18. I am afraid that if I do make this change‚ it might make my life worse in some ways.
19. If I make this change‚ it might mean that I will have to give up some of the things that I enjoy.
20. I don’t think I’ll be successful in making this change if I try.
21. I am afraid that in some ways I’ll feel worse and not better if I make this change.
Part 3
FEELINGS ABOUT THE CHANGE
1. Optimistic
2. Nervous
3. Ambitious
4. Frustrated
5. Determined
6. Cautious
7. Enthusiastic
8. Confused
9. Hopeful
10. Worried
11. Strong
Part 1&2: 0=Applies to me little or not at all‚ 1‚ 2 Applies to me somewhat 3‚ 4‚ Applies to me very much
Part 3: 0=Not at all‚ 1‚ 2 Moderately 3‚ 4‚ Strongly=5
This instrument can be found at: http://arizona.openrepository.com/arizona/bitstream/10150/195528/1/azu_etd_11159_sip1_m.pdf
Brody‚ Amanda E. “Motivational interviewing with a depressed adolescent.” Journal of Clinical Psychology 65.11 (2009): 1168-1179. Web. 20 Feb. 2011.
Cohen‚ Julie L.‚ (2010). Enhancing Retention of Foster Parents: The Role of Motivational Interviewing and recommend that it be accepted. University of Arizona. Doctoral Dissertation