1/30/2023 EnchantaVaughn Approved 1. Behavior: When QMHP saw client, client presented with a bright affect. Client presents good well-being and appearance. Client verbalized positive feelings about seeing her counselor. Client seemed ready for the session, as evidenced by client making good eye contact, sitting up straight, and waiting for directions. Client was respectful of her counselor. Client had appropriate interaction with everyone in the home as she communicated her concerns. Client was having appropriate conversation and speaking her mind with QMHP, demonstrating confidence. Client expressed excitement about helping her mom today. Client spoke calmly, but also listening when mother was sharing her thoughts about her observations of client behaviors. The family showed positive manners by saying please, excuse me, and thank you. The family interacted well with one another and spoke to each other calmly and effectively. The family did not need much redirection as the family session continued. Client presented a good attitude throughout the session. Client displayed good participation and communication throughout the session. 2. Behavior: Client responded well to the exercise, demonstrating she was learning and understanding the lesson as it pertains to her struggles and challenging areas. Client have been proactive about working on herself and presenting a better attitude in the home. Client was supported with managing her symptoms well throughout the session and needing little to no redirection. Client was courteous to authority requests and demands. The client was provided with positive feedback as she displayed a realistic understanding of her recurrent pattern of mental illness symptoms. Client seemed to be in a calm mood, as evidenced by her positive expressions and relaxed demeanor. Client was able to stay inside the house without any incidents. The client is beginning to show more trust in others as demonstrated by increased social interaction in the home. Client talked a lot about the good things that happened today and less about things that didn’t matter. Client was praised for having a wonderful end to her day and encouraged to keep up the good work. 1. Intervention: QMHP reflected with client on her day, reviewing both good and bad experiences. QMHP processed with client regarding positive decision-making skills. QMHP encouraged client to have a good evening. QMHP supported client with displaying positive social interactions with peers and authority. QMHP reinforced appropriate coping skills in the home. QMHP processed client positive responses and challenged client to maintain appropriate behaviors throughout the entire week. QMHP assisted client in monitoring her own behaviors in efforts to promote exercising self-control in focused areas such as respecting boundaries with her family, peers, and counseling staff. QMHP modeled proper positive behavioral expectations for the client. QMHP introduced concept of nonverbal communication cues in efforts to review the expected behaviors or results to the nonverbal cue. QMHP implemented a routine that will encourage client to be responsible and promote self confidence in academic and social settings. QMHP prompted client to do her best no matter what. QMHP continued to establish a positive supportive relationship with client. 2. Intervention: QMHP observed client in her own space to determine if she required assistance. QMHP talked to client about her confidence levels and how much she has shown in believing in herself and taking accountability. QMHP encouraged client to utilize positive self-talk as a means of decreasing anxiety and managing frustration when encountering difficult or challenging circumstances. QMHP reminded client of her strengths and abilities. QMHP praised client for her efforts and being respectful to her mom. Her mom expressed cheerful attitude toward client, indicating everyone was on the same page and focusing on achieving her goals. QMHP provided strategies such as positive reframing. Client was able to reduce physical overactivity and become more attentive in session. QMHP discussed with the family one goal they believe they need to work on individually and as a family. QMHP had each member write down goals and discussed through brainstorming and creating a goals chart on how to achieve each one. QMHP offered simple suggestions to the client for behaving appropriately in the home and community and encouraged client to practice the positive behaviors at school too. 1. Response: Client responded in a pleasant manner acknowledging the positive reinforcement that the QMHP provided. Client is making progress with expressing her feelings and showing others respect and courtesy by talking with appropriate tone initiating conversation with her age group. Client said she loves outside activities and utilizes this to relax and stay focused. Client communicated she goes trailing. Client seemed to be really happy with this new hobby and exercise. Client exhibits determination in the home setting. Client nodded in understanding and communicated that she was going to continue making good choices and show positivity around others. Client was attentive and successfully planned her day so that she had enough time to do chores, complete her homework, and help her mom around the house. Client presents moderate self-esteem throughout the session, as evidenced by utilizing creative strategies to stay motivated and on task. Client was responsive to the interventions and attempted to implement skills right away. Client focused on things she is good at and loves to do at home in order to stay motivated in the school/community settings. Client displayed positive thoughts throughout the session. 2. Response: Client was receptive and open to the interventions, as she was attentive and focused on the information and activities that were being processed without any difficulties. Client was able to process making good choices with QMHP and her mom. Client appeared to be receptive to receiving positive reinforcement from her counselor as demonstrated by her smile and open body language. Client smiled as she was affirmed for her mature and pleasant behaviors. Client was able to communicate with the QMHP. Client communicated that she felt safe and comfortable talking to the in-home counselor about things she’s going through. Client shared some of the things she does at home to help her relax. Client participated in reviewing key concepts on her mental illness and how to manage the symptoms. Client is starting to express more passion for school, being at home, and doing her best virtually as well. Client showed good understanding of what it means to be respectful, encouraging, mindful, and fair to others. Client displayed self-determination to stay focused and pay attention while QMHP went over each prompt. Client was pleasant and cooperative and demonstrated a willingness to discuss the factors contributing to her mental disorder.