AGWellness
Readiness to Change Questionnaire
Let’s start with the basics
Name
Email
Do you have a goal in mind?
Yes
No
If you answered yes to the previous question, what is your goal?
If you answered no, type N/A
Are you prepared to make this goal a top priority?
Yes
No
Not sure
Have you tried achieving this goal in the past?
Yes
No
Kinda
Do you believe there are risks/danger in NOT achieving this goal
Yes
No
Maybe
On a scale of 0-10, how committed are you to achieving your goal, even if it proves challenging?
0 being not committed at all & 10 being you’ll walk to hell and back to make it happen!
Do you have support from family, friends, or others to help you achieve this goal?
Yes
No
Maybe
Why is achieving this goal important to you?
Are you willing to be patient with yourself & the process if/when you face obstacles, barriers, & setbacks?
Yes
No
Submit
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