1/25/2023 EnchantaVaughn Approved 1. Behavior: When the QMHP came to the residence, client personality was viewed as happy, well-mannered, and compliant. Client displayed helpful and supportive behaviors towards her mother as she assisted her with her chores. Client communicated pleasant and kindhearted manners toward QMHP as she transitioned to the session. Client exhibited appropriate conversation. Client was respectful and polite to her mom when she asked her to clean up behind herself. Client was seen cleaning up behind herself and displaying appropriate conduct in the home setting. Client enjoys being a part of in-home therapy, as evidenced by her laughing and smiling while conversing with QMHP. Client implemented the rules and expectations while processing and reflecting on her day. Client was able to manage her emotions correctly. Client was respectful to her little sister, sharing and taking turns playing different games in her room. Client displayed excellent teamwork and relationship building skills and was applauded for her positive interaction. Client was receptive to QMHP prompts and directives. Client was open to sharing with QMHP her feelings and the things she believed she needed the most assistance with. Client expressed having a counselor helps her mom out a lot. Client was supported for being on task and cooperative while counselor administered the next activity. 2. Behavior: Client appears to be learning and enjoying her day. Client remains quiet and seated throughout the session. Client showed high level of participation, waiting for instructions, and giving excellent eye contact indicating she was paying attention and listening. Client was patient and polite, following along with the interventions. Client was calm and collective during individual activity. Client remained cooperative and compliant. Client stated she felt good. Client was able to appropriately ask for help when she didn’t understand directions. Client was able to verbalize positive feelings and emotions in the home. Client was given positive feedback about her efforts and contributions. Client responded well to feedback, exhibiting respectful and pleasant mannerisms in family setting. Client did not view any behaviors that could be perceived as negative or inappropriate. Client stated she liked taking small breaks during session so that she doesn’t get tired or bored. Client did a good job maintaining appropriate communication with QMHP. Client exhibits the appropriate attitude that is encouraged and inspired by mom and mental health professional. Client complies to authority directives without complaining. Client is observed focusing on her work and ignoring distractions. Client was able to reduce symptoms of ADHD. 1. Intervention: QMHP actively listened and provided support to client when needed. QMHP inquired about how client was feeling. QMHP made sure client was comfortable and in a good space before introducing her to new therapeutic skills to practice at home. QMHP revisited effective communication skills and positive verbal affirmations with client to help her express herself in a calm and open way. QMHP examined and evaluated client’s demeanor in order to manage her compliance with following rules. QMHP will brainstorm strategies with client and encourage self-monitoring. QMHP commended client on utilizing coping strategies to increase her understanding of feelings and emotions. QMHP processed client positive behaviors toward her siblings. QMHP provided positive words of praise and reassurance to encourage and promote confidence and respect for herself. QMHP asked client open ended questions to get her to interact and to increase her participation. QMHP reminded and practiced breathing and relaxation techniques to teach client the importance of the “stop, think before act” method. QMHP assisted client with finding and utilizing necessary resources to assist with her daily habits and routine. 2. Intervention: QMHP held consultations with client and mother about effective intervention strategies that build on the client's strengths and personal attributes. QMHP encouraged client’s mother to provide frequent positive reinforcement to maintain client's interest and motivation in maintaining positive behaviors and completing her chores around the house, including all therapeutic assignments given by QMHP. QMHP went through program overview with client and mom to reiterate key points and program objectives that would pertain to client specific wants and needs. QMHP reiterated to the client the support she would bring in order to assist client in achieving her goals. QMHP brainstormed possible ideas for activities to facilitate with client that she may be more interested in than the educational worksheets and video presentations that she’s participated in the last few sessions. QMHP encouraged client to continue displaying positive behaviors in the home. QMHP supported client involvement in virtual therapy and virtual learning, in order to accommodate other areas that are challenging to her. QMHP encouraged client to practice relaxation and coping techniques in virtual/academic environment, at home, and in the community. 1. Response: Client understood the expectations and rules for one on one session. Client and mom verbalized that they are doing well with communicating with each other since being back together. Client was receptive and open to the information that was provided by QMHP, as she listened attentively to all that was presented to her regarding her behaviors. Client was able to express her feelings and moods in a positive way without getting upset. Client stayed on task and returned a sociable and friendly rapport back to mental health counselor without any negativity. Client participated and cooperated well with her family. Client was able to answer the thinking questions with assistance from counselor. Client asked questions to counselor concerning her mental health. Client was able to demonstrate positive interaction and excellent manners without having an episode. Client said thank you and continued to display healthy manners in the home. Client displayed high self-esteem and confidence with meeting her objectives. Client was observed practicing breathing and relaxation strategies and mastering the “stop, think, act” method. Client was acceptive of QMHP support. Client followed all directions, as she demonstrated ability to adhere to the rules and expectations of individual session. 2. Response: Client was receptive and actively participated in the therapeutic activity. Client was able to use her active listening skills to pay attention and concentrate in her session. Client expressed non-aggressive emotions and showed respect to her counselor when asked questions about how she deals with stress. Client verbalized good thoughts and understanding, at this time. Client developed better communication skills by expressing herself in a calm manner. Client displayed management of individualized behaviors in the home. The client has not overreacted with anger to minor frustrations or irritants. Client understood her expectations and what ways she could utilize the session to best fit her learning style. Client responded well to QMHP and appeared thankful for the consistent help and support. Client shared some of her favorite things to do and places to go that could accommodate her specific needs. Client implemented good communication skills by listening attentively and closely. Client displayed full participation during family activity. Client developed coping skills by being able to practice observing more consciously and taking notice of other’s feelings. Client hyperactive and impulsive behaviors were reduced, and symptoms of ADHD are stabilized.