Embracing Autonomy for Self-Motivation

Name: Click here to enter text. Date: Click here to enter text.

The Self-Determination Theory states that in order to make a change in your life you
need the competency to make the necessary change, feel connected to others in
your life, believe that you have control over your life, and that you have hope and a
purpose in the change you desire to make.
Section A of this survey has you reflect where you are on having met all these
requirements. If you rank a 2 or below on any of the items, you need to improve it
to at least a 3 to be able to make the change in your life. However, you can work on
improving each item while working towards your goal. In Section B, you are directed
to identify the problem description, goals and objectives, interventions, and the
duration of accomplishing the goal. After creating this plan, you will create an
individualized safety network that will help keep you motivated and working
towards your goal. By signing your name at the bottom, you are promising and
holding yourself accountable to keep yourself motivated and accomplish your
designated goal. By completing the survey, the power to change and remain
motivated is put back into your hands.

Section A: Feelings of Motivation and Achieving Goals

Goal: Click here to enter text.

Rate and fill out each item according to how you feel right now. Then rank in order
of importance 1 to 5 of completing your goal (1 = most important to 5 = least
important)
1) RATE COMPETENCY (skills and know-how to achieve your goal):
Low competency: 1 2 3 4 5 : High competency
What I find to be most competent in: Click here to enter text.
2) RATE RELATEDNESS (how connected you feel to others in your life):
Low relatedness: 1 2 3 4 5 : High relatedness
Who am I most connected to: Click here to enter text.
3) RATE AUTONOMY (feelings of control over your life and decisions):
Low autonomy: 1 2 3 4 5 : High autonomy
I feel the most control over my life when: Click here to enter text.
4) RATE HOPEFULNESS (your expectation that things will get better):
Low hopefulness: 1 2 3 4 5 : High hopefulness
I am most hopeful about: Click here to enter text.
5) RATE PURPOSEFULNESS (the goal you are trying to achieve has a
purpose you believe in):
Low purposefulness: 1 2 3 4 5 : High purposefulness
What purpose do I most believe in: Click here to enter text.
6) RATE OVERALL LIKELIHOOD OF ACHIEVING GOAL
Extremely low likelihood: 1 2 3 4 5 : Extremely high likelihood

1) How much is being motivated related to thoughts and feelings about yourself?
Not at all: 1 2 3 4 5 : completely
2) How much is being motivated related to thoughts and feeling about others?
Not at all: 1 2 3 4 5 : completely

RANK REASONS FOR ACHIEVING GOAL RANK REASONS FOR NOT

ACHIEVING GOAL
1. Click here to enter text. 1. Click here to enter text.
2. Click here to enter text. 2. Click here to
enter text.
3. Click here to enter text. 3. Click here to enter text.
4. Click here to enter text. 4. Click here to enter
text.
5. Click here to enter text.
6. Click here to enter text.
7. Click here to enter text.
8. Click here to enter text.

I wish to achieve my goal to the following extent: Not at all: 0 1 2 3 4 5 6 7 8 :

Very much
I wish to NOT achieve my goal to the following extent: Not at all: 0 1 2 3 4 5
6 7 8 : Very much
The one thing that would help me feel motivated would be: Click here to
enter text.

Section B: Motivation Plan

Proble Problem Goals and
Interventions Duration
m Description Objectives

3
Problem Description: problem that is addressed by accomplishing goal
Goals and Objectives: specific goal to accomplish
Interventions: plans to accomplish goal
Duration: target time to accomplish goal

Ways to increase external motivating influences:

1.Click here to enter text.
2.Click here to enter text.
3.Click here to enter text.

Action steps I can take to increase my motivation:

1.Click here to enter text.
2.Click here to enter text.
3.Click here to enter text.
4.Click here to enter text.
5.Click here to enter text.

People I can call for help or to increase motivation:

1.Click here to enter text.
2.Click here to enter text.
3.Click here to enter text.

Potential barriers of increasing motivation to achieve goal:

1.Click here to enter text.
2.Click here to enter text.

Solutions I will try to increase motivation to achieve goal:

1.Click here to enter text.
2.Click here to enter text.

YES NO I understand and concur with my motivation plan?

My Signature Date
Click here to enter text. Click here to enter text.
Adapted from CAMS (Collaborative Assessment and Management of Suicidality) by
Dave Jobe at the Catholic University of America, 2012.