8/29/2023 EnchantaVaughn Approved Behavior: Client appeared to be in an exquisite mood, as evidenced by her genuine smile and energetic spirit. Client was happy to be outside and enjoyed being in the community for a short while but was careful to social distance with everyone she came in contact with. Client displayed excellent conduct and complied to authority requests. Client was excited and communicated she wanted to go somewhere to clear her mind. Client was happy to see some of her friends in the area and waved and smiled to them as she passed by. Client interacted well in the session and was supported for her effort and commitment with all of her objectives. Behavior: Client has demonstrated good coping skills throughout the day by not allowing things out of her control to get the best of her. Client acknowledged the small wins, despite circumstances. Client was appreciative of the therapeutic services and having someone to depend on that understood her on serious and fun levels. Client commented that she felt good. Client reflected on what it has been like for her in the summer time. Client was cheerful and expressed honor and felt more responsible with making sure she helps around the house and help her mom with the chores more now that she’s at home more often. Intervention: QMHP observed client complying with rules and expectations. QMHP utilized empathetic listening skills as client expressed her understanding of stressful situations. QMHP provided age appropriate understanding of the mom’s perspective of the situation and why she is there to help resolve any issues, including but not limited to her mental health. QMHP supported client with working on herself and trying her best to understand the purpose of each session. QMHP informed client that refusing to listen to her mom was not acceptable and she should take small personal breaks and then process forward. Intervention: QMHP reminded client of ISP objectives. QMHP processed client thoughts and feelings. QMHP engaged client in conversation regarding her recent behaviors, progressions, and setbacks. QMHP explored client’s responses and provided appropriate feedback. QMHP explained the importance of being on task and refraining from talking in order to complete her assigned task. QMHP reviewed examples of alternative appropriate behaviors she could engage in. QMHP supported client making good decisions and having positive behaviors in the home. Response: Client demonstrates she can accept compliments and constructive criticism and act civilized if she tries hard enough. Client exhibits good attention skills and remained focused. Client reviewed ISP objectives with mental health professional. Client said she was aware of her expectations and what she is expected to do each day. Client practiced some of the examples of alternate behaviors (e.g. closing her eyes and thinking about happy memories, coloring/drawing pictures, repeat positive “I-statements” 10-15 times, and ask questions) that will help her understand things better. Response: Client was observed in session adhering to rules and regulations and being respectful to staff. Client displayed self-control in her seat by keeping her hands in her lap and sitting calmly without impulsive or hyperactive behaviors while counselor reviewed her objectives and expected her to give an example of how she displayed each one in the home today. Client did a good job ignoring distractions and maintaining appropriate behavior in the session. Client transitions well between one on one discussion and family discussions, utilizing the correct voice volume and displaying positive body language the entire time.