CBT Change Record
The purpose of this exercise is to identify and alter negative thinking patterns that cause emotional distress, maintain unhelpful behaviours and interfere with tasks and responsibilities. Complete all sections of the exercise before submitting your results. You can respond anonymously, and no data will be retained from this assessment. If you choose to include your initials and an email address, your results will be automatically sent to the email address provided. Please check that the email address has been entered correctly before submitting this form. All client information is managed on a strictly confidential basis. Please Note: Whilst every effort is made to ensure that our system is securely encrypted, email is not a completely secure means of communication. Think CBT does not accept liability for loss or theft of personal data where any individual chooses to transmit or receive information via email.
Send my assessment results by email:

1. Situation / Trigger – What triggered the problem; this could be an external event, a memory, image, feeling or sensation?
2. Initial Response - when this happens, how do I feel emotionally and physically; what do I do?
3. Intensity of Reaction

4. Negative Automatic Thoughts – What unhelpful thoughts, assumptions or beliefs go through my mind; rate the strength of each thought 0-100% and identify the “Hot Thought”.
5. Supporting Evidence / Benefits - What tangible facts / benefits support the hot thought?
6. Opposing Evidence / Costs - What tangible facts / benefits oppose the hot thought?
7. Cognitive Distortions – Which of the following thinking errors apply?

8. Alternative Response – How does changing my interpretation in this way, help to alter my initial response?
9. New Coping Strategies – What steps can I take to pre-empt the problem and improve the way I respond in future?
10. Having completed this exercise, how do I feel emotionally and physically; what will I do?
11. Re-rate reaction. How strong does the reaction feel now?