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Change Assessment Template

Are you looking for a way to assess the readiness of your clients to make a change? The Change Assessment Template has been designed to provide you with an easy-to-use tool to evaluate the motivation of your clients and to create an action plan to move them through the stages of change.


This template is inspired by the Transtheoretical Model of Change, which is a widely accepted framework for understanding how people move through the process of change. With this template, you can quickly assess your clients' current stage of change and create an action plan to move them through each stage.


The Change Assessment Template is an invaluable tool for any professional who is working with clients who are looking to make a change in their lives. It provides an easy-to-understand framework for assessing a client's readiness to make a change and for creating an action plan to help them move through the stages of change.

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Read the following statements and choose strongly agree, agree, neutral, disagree, or strongly disagree for each one.

Change Assessment Template

  1. As far as I’m concerned, my low self-worth isn't a problem that needs changing.
  2. I think I might be ready for some self-improvement.
  3. I am doing something about the low self-worth problems that had been bothering me.
  4. It might be worthwhile to work on my low self-worth problem.
  5. My low self-worth isn't a problem. It doesn’t make much sense for me to be here.
  6. It worries me that I might slip back on a low self-worth problem I have already changed, so I am here to seek help.
  7. I am finally doing some work on my low self-worth problems.
  8. I’ve been thinking that I might want to change something about myself.
  9. I have been successful in working on my low self-worth problem but I’m not sure I can keep up the effort on my own.
  10. At times my low self-worth problem is difficult, but I’m working on it.
  11. Trying to change is pretty much a waste of time for me because the low self-worth problem doesn’t have to do with me.
  12. I’m hoping this place will help me to better understand myself.
  13. I guess I have faults, but there’s nothing that I really need to change.
  14. I am really working hard to change.
  15. I have a low self-worth problem and I really think I should work on it.
  16. I’m not following though with what I had already changed as well as I had hoped, and I’m here to prevent a relapse of the low self-worth problem.
  17. Even though I’m not always successful in changing, I am at least working on my low self-worth problem.
  18. I thought once I had resolved the low self-worth problem I would be free of it, but sometimes I still find myself struggling with it.
  19. I wish I had more ideas on how to solve my low self-worth problem.
  20. I have started working on my low self-worth problems but I would like help.
  21. Maybe this place will be able to help me.
  22. I may need a boost right now to help me maintain the changes I’ve already made.
  23. I may be part of the low self-worth problem, but I don’t really think I am.
  24. I hope that someone here will have some good advice for me.
  25. Anyone can talk about changing; I’m actually doing something about it.
  26. All this talk about psychology is boring. Why can’t people just forget about their low self-worth problems?
  27. I’m here to prevent myself from having a relapse of my low self-worth problem.
  28. It is frustrating, but I feel I might be having a recurrence of a low self-worth problem I thought I had resolved.
  29. I have worries but so does the next person. Why spend time thinking about them?
  30. I am actively working on my low self-worth problem.
  31. I would rather cope with my faults than try to change them.
  32. After all I had done to try and change my low self-worth problem, every now and then it comes back to haunt me.
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