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Mindfulness Diary
Jessica Gundy Cuneo
Over the next week, choose three to five different time periods to complete this form. Be sure to fill in all of the
information each time. Here are the steps for using the form:
1. Choose a mindfulness activity to engage in.
2. Prior to beginning the exercise, decide on a specific time and place where you will do this mindfulness
practice. This may be a quiet place with no distractions or, conversely, a place where distractions are
likely to occur.
3. Just before beginning the activity, note any inner experiences you may be having: thoughts, feelings,
physical sensations, or memories.
4. Note how long you practiced.
5. Did anything help, hinder, or interfere with doing the practice?
Permission granted to the reader to reproduce this form for personal use.
© 2014 Jill A. Stoddard and Niloofar Afari/New Harbinger Publications.
Mindfulness Diary
The Big Book of ACT Metaphors ACT Thought Record
The purpose of this diary form is to help you become increasingly aware of the feelings and thoughts that show
up in a variety of situations you experience throughout the week, and to give you the opportunity to practice
acceptance and present-moment awareness strategies and choose actions that are in line with your values. Over
the next week, choose three to five different situations to examine with this form. Be sure to fill in all of the
information each time.
1. Briefly describe the situation.
2. Record the feelings you notice, including emotions and physical sensations.
3. Record the thoughts going through your mind as you are in the situation.
4. Practice one of the present-moment awareness exercises that help with observing inner experience, rec-
ognizing thoughts as thoughts and feeling as feelings. Note any responses you have to allowing thoughts
and feelings to come and go.
5. Take a few moments to identify your values that are salient in this situation.
6. Choose an action or response that’s in line with your values.
Attitude Culture
Beautiful Good
Bad
Body
Fearful Sensations Sad
Listening
History
Sound Family
History
Vibrations
Happy Relaxed
Touching Moving
Suspenseful
Mood Personality
Expertise
This an
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example represents
of how we an can
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thoughts. The experience of listening to
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music can provoke many thoughts.
powerful The experience
sensations, thoughts,of listening toevaluations,
experiences, music can provoke many Consider that this is
and judgments.
powerful sensations, thoughts, experiences, evaluations,
exactly what our minds do—this is programming and it is happening all the time. and judgments.
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it is happening all the time.
further away the circles are from the musical event, the more variable and subjective the emotions become. This process
accounts for the individual variables
At the centerand factors
of the influencing
circle our experience,
is the musical which make
event that represents up the
“just “our story.”
facts” of “what actually happened.” The further away the circles are from the
musical
© 2014event,
Jill A.the more variable
Stoddard and subjective
and Niloofar the emotions
Afari/New Harbinger become. This
Publications.
process accounts for the individual variables and factors influencing our
Permissionwhich
experience, granted to the
make reader
up “our to reproduce this form for personal use.
story.”
The Big Book of ACT Metaphors Values Words
Values Words
Nicole Rensenbrink
Below is a list of words that may help you generate ideas about your values. Note that some of these words, like
Calm, Patience, and Courage, may refer to internal experiences. In these cases, the value may be to act calmly or
with patience or courage, even if you don’t feel this way. The value should not be to achieve an internal feeling state.
Think about who your heroes are and choose a few people you admire. These may be people you know, celebri-
ties, or even fictional characters. On the following sheet, write in the columns provided:
1. The name of your hero
2. The values this person embodies that you admire
3. Actions you can take to start moving in the direction of being more like this person
4. Obstacles you anticipate (e.g., thoughts, feelings, urges, memories) that might get in the way of your com-
mitted actions
5. Skills and/or exercises you might use to handle obstacles so that you can keep your feet moving toward
being more like your hero
Permission granted to the reader to reproduce this form for personal use.
© 2014 Jill A. Stoddard and Niloofar Afari/New Harbinger Publications.
The Heroes Exercise Worksheet
The Big Book of ACT Metaphors Writing Your Autobiogr aphy Worksheet
After taking ample time to think about your autobiography as it would appear after you’ve lived a truly meaning-
ful, fulfilling life that was full of vitality, write down the values that were expressed through your personal story.
After taking time to think about your autobiography as it would appear if it were written about you today, write
down what showed up.
Now write a few thoughts about any discrepancies that arose when comparing your ideal autobiography to your
present-day story.
Permission granted to the reader to reproduce this form for personal use.
© 2014 Jill A. Stoddard and Niloofar Afari/New Harbinger Publications.
Values and Committed Action Worksheet
The Big Book of ACT Metaphors The Classroom Professor Gr aphics and Worksheet
Pebble
Ping-Pong ball
Ping-Pong Balls
1.
2.
3.
4.
5.
6.
7.
8.
Small Rocks
1.
2.
3.
4.
5.
6.
7.
8.
Sand
1.
2.
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