2/7/2023 EnchantaVaughn Approved 1. Behavior: Upon arrival, client was present and very relaxed when QMHP knocked on the door to pick her up. Mom appeared to be a little frustrated about not hearing from anyone about virtual school with school beginning in a week. Mom doesn’t feel as prepared for her daughter to move forward without an individualized educational plan in place. Mom needed answers and had been waiting for more information. Client handled herself well and didn’t let her mom’s mood get her upset or discouraged. Mom explained that she was going to be okay and approved client having session outside the home today. Mom wanted client to get the most out of in-home services. Client expressed that she wanted to give her mom a break so that she could rest. Client was very concerned about mom and asked if she needed anything before leaving. Client was given a thumbs up for showing positive emotions and exhibiting empathy in the home. Client was happy to see her counselor and thanked her for coming over. Client displays good behaviors during the session. No redirection was needed at this time. Client was compliant and respectful and waited her turn to speak without interrupting QMHP. Client displayed excellent behaviors in the home today. Client expressed that her favorite part is including her family and being surrounded by positive energy. Client shared that she is learning to develop the skills needed to achieve her goals on a daily basis and is proud at how far she has come. Client admitted that her and her mom are getting along better and she’s beginning to see the value in family time and spending quality time with her loved ones. 2. Behavior: While client participated in services, it is apparent client need psychological help, as well as, tutoring. Although client have picked up bad habits by being used to no responsibilities and having the luxury to stay up all night and do whatever she wants, client have shown some consideration for her mother’s anxiety and stress with her education. Client and QMHP discussed client’s behavior at home this week. Client followed all directions given by mom and counselor. Client made constant eye contact during session and displayed a calm demeanor without getting angry or frustrated. Client was observed interacting on an age appropriate level and making it easy to conduct the session without having to redirect her or take small breaks. Client was able to complete the session and learn new skills that she plans to practice with mom for a few minutes each day. Client was in a happy mood and expressing healthy emotions toward the activity provided by QMHP. Client did her best to ignore distractions and stay on task. Client was observed displaying appropriate manners by sitting properly in her seat and being quiet when QMHP explained the activity and directions in the session. Client exhibited appropriate social behaviors around her family. Client displayed appropriate conversation with her counselor and mom throughout the session. 1. Intervention: QMHP conducted session on helping family reduce the stressors in the home so that everyone feels safe. QMHP informed mom that client can benefit from other services, thus probing them to utilize resources in the community that will help client reduce her aggressive behaviors. QMHP reviewed with mother the ability to limit the stress in the home and to utilize the reward system. QMHP utilized active listening skills while probing mother on the affect ways that she attempts to reduce client's negative behaviors. Mother was praised for her efforts to better herself and her living situation by making sure she provides client with everything she needs to move forward and keep client away from negative influences. QMHP will provide client with support and encouragement. QMHP will monitor, observe, and redirect client behaviors as needed. QMHP will continue to build a rapport. QMHP will explore positive self-talk, use instruction modeling, and increase social communication skills with positive reinforcement role play activities. QMHP will educate client on behavior modification to help client identify what behavior she needs to decrease and avoid daily. QMHP will utilize behavior modification system to aid the client with following directions given by authority figures. QMHP inquired about after school activities. QMHP will meet with client 4x a week to discuss progress and expectations that are working and not working in the home. 2. Intervention: QMHP engaged client in a session on the importance of exploring conflict resolution skills. QMHP educated the client during the session that conflict involves having a disagreement with someone over opposite opinions. QMHP shared with the client that no matter how hard we try to avoid a conflict they are sure to keep happening if we don’t learn to be problem solvers. QMHP explained that it is possible to learn how to resolve conflicts in such a way that everyone is happy and get what they want. QMHP processed with the client and shared some positive ways to resolve conflicts, such as peer mediating, talking to an adult about the situation, using I feel statements to express how you feel so you do not offend the other person. QMHP challenged client to explain how she would resolve a conflict in a positive manner using one of the methods discussed or using another positive method. QMHP educated client about appropriate touch and personal boundaries. QMHP processed client thoughts and feelings. QMHP engaged client in conversation regarding her recent behaviors, progressions, and setbacks. QMHP modeled proper positive behavioral expectations for the client to encourage additional layers of support and understanding of rules and expectations. QMHP explored client’s responses and provided appropriate feedback. QMHP supported client making good decisions and having positive behaviors in the home. 1. Response: The family recognized the part they played in contributing to the stress in the home. Mom was grateful to know there were other services available to her and she confirmed she would utilize them. Mom looked forward to client getting better and being less tense in the home so that she wouldn’t influence her little sister. Client appeared to be receptive to QMHP’s interventions and services that were provided to her during the session. Client reported that her and mom have a close relationship but have difficulty with communicating when client is upset. It was communicated by parent that client needs to realize that she has a lot going for herself, but she allows others to get her off track. Client was able to deescalate once given a new discussion topic, but only minimally participated as she continued to be guarded. Client is aware that she can be a hand full. Client admitted that she can’t control her temper sometimes. Client reported that she is looking forward to receiving help and wants to learn how to deal with her anger and depression. Client understands that her treatment plan is a behavior contract that will reflect her improvements in the home. Client stated that she is open to new ideas. Client was acceptive of prompts given by mom and counselor. Client agreed to listen to the adult and follow all rules no matter if she sees someone else breaking them. Client is reminded to tell an adult if someone is interrupting her learning no matter where she is. Client presents a positive attitude when given the opportunity to earn a reward. Client implemented the positive reinforcement provided by her mom and was able to stay motivated and enjoy her day. Client exhibited good manners after earning incentive for her hard work. Client said, “thank you” and smiled transitioning into next activity. 2. Response: Client displayed good engagement during second half of session. Client understood the importance of resolving conflict and being a problem solver. Client tried her best not to create drama in the house and be a good example to her little sister. Client admitted that some of her tension come from not receiving the love and attention she desires by her parents. Client stated that she wished she could spend time with her father who is absent in her life. Client informed QMHP that she has been learning a lot in each session. Client thanked QMHP for helping her family communicate with each other in a more positive and productive way. Client stated that talking and sharing things in her life helped her to evaluate her poor choices and correct her mistakes. Client went on to report that she will practice therapeutic techniques with her family when she feels that it is the right time and place. Client has attempted to utilize what she acquired from today’s and previous sessions to reduce symptoms of ADHD. Client responds well to praise and support. Client is striving for a good report from school every day. Client wants to make her teacher and parents proud by doing a good job. Client is very independent but can be a team player as well. Client is observed problem solving on her own and handling her emotions appropriately. Client responds well to feedback. Client responds well to the positive reinforcement provided by QMHP and is seen increasing self-esteem and confidence. Client said she was going to practice coping strategies and relaxation techniques in all aspects of her daily living routine in hopes that she will be a better person, sister/daughter, and friend.