My Modification Commitment

I hereby commit to, and accept responsibility for, achieving the goals that I have initialed below. In addition, they demonstrate my motivation, confidence and commitment to the moderate my use. I understand that a slip does not give me permission to return to my old pattern of drinking, and I acknowledge that it is in my best interest not to exceed 3 drinks.

1. I have completed 30 days of abstinence to first reduce my tolerance.
2. I will not drink in my home, any drinking must take place at __________________
3. I will spend as much time as possible in areas where drinking is prohibited.
4. I will avoid places where there are temptations to drink, such as bars and time with friends who drink.
5. I will not meet a friend to drink if I know it is a situation in which I will exceed my goal.
6. I will drink an extra two-four glasses of water each day.
7. I will throw away all of my personal alcohol.
8. I will not exceed a two drink limit to begin with and I will drink water or another beverage in between drinks to help space and sip.
9. I will change my drink to something I don’t care for to make it less inviting.
10. I will keep a daily record of my drinking.
11. I will reduce my drinking from __________ drinks and no more than __________ a week.
12. I will begin or increase my physical activities to __________________ times per week.
13. I will make an appointment with the University Health Services (574- 631-7497) or primary care physician for a physical health examination, and explore medical options to aid my moderation.
14. I will make an appointment with the university nutritionist or local nutritionist.
15. I will reward myself for accomplishing these goals by: ____________________

Signature:______________________ Date:__________________

Drink Log for Modification

Week 1

Week 2

Week 3

Week 4