Name: Date: Goal:
Why do you want to achieve What has kept you from achieving What resources do you have to help What steps are you going to take to achieve your
this goal? your goal? you achieve your goal? goal?
What is your motivation?
Name: Julie Johnson Date: 11-11-10 Goal: Start going to the doctor
Why do you want to achieve What has kept you from achieving What resources do you have to help What steps are you going to take to achieve your
this goal? your goal? you achieve your goal? goal?
What is your motivation?
Improve my health Don’t currently have a doctor Support and love from my family 1. Access Coordinator will help my find a doctor
Live longer Scared of hospitals Bus stop near my house 2. I will call and make my first appointment
Take care of my children Busy taking care of my family I have friends who go the doctor, I can talk 3. I will ask my case manager for a bus ticket
See my child graduate from Transportation with them about it 4. Access Coordinator will call me one week before
high school Money Access Coordinator can help me find a doctor to remind me of my appointment
Be a good example to my Don’t know where to start I want to do this 5. I will ask a friend how to get to the clinic
family Scared to know if my health is good or I have a home and food to eat each night 6. I will write down my questions for my doctor
Prove to myself that I can do it bad Neighbors can check on my children when before I go
I have an appointment 7. Access Coordinator will meet me a the clinic
8. After my appointment I will check in with my
Access Coordinator in case I have any
questions
9. I will ask my case manager for help getting
prescriptions, if I need any
10. I will write down the time of my next
appointment on my calendar and will tell
my Access Coordinator
11. I will call my Access Coordinator or doctor if I
have any questions
12. My Access Coordinator will remind me 1 week
before my next appointment and will meet
me at the clinic
Name: Jim Johnson Date: 11-11-10 Goal: Go to AA meetings three times a week to stay sober
Why do you want to achieve What has kept you from achieving What resources do you have to help What steps are you going to take to achieve your
this goal? your goal? you achieve your goal? goal?
What is your motivation?