1/29/2023 EnchantaVaughn Approved 1. Behavior: The client was appropriately dressed upon the QMHP’s arrival to the residence. Client was in the living room watching tv with his brother. Client appeared to be in a pleasant mood, as evidenced by his calm and subtle facial expressions and discussions. Mom appeared to be in a good mood as well, as observed by her demeanor and verbalizations while walking in the room. During the session the client was alert and focused. The client however struggled to maintain appropriate voice volume and had to be constantly reminded to lower his voice. The client’s behavior was acceptable as he was respectful and cooperated with the counselor when prompted or redirected. Client was alert and had a pleasant mood. Client expressed he was excited for the weekend and couldn’t wait to spend time with his aunt. Client was aware that in order to have a good day and be rewarded he has to do the right thing at all times, as well as complete all of his work. Client agreed to be respectful and listen to his mom. Client shared some of the interesting things that happened at home today. Client loves his day treatment program and counselor. Client talks a lot about the fun activities he does and wants to do at home with his family this weekend. Client stated he looked forward to seeing his friends. Client is doing a much better job utilizing his therapeutic journal to manage his anger and get back on track. Client verbalizes positive expressions during his therapy sessions and greets his counselor with a smile and hug every day. Client continues to make progress with achieving ISP objectives, due to identifying anger triggers. utilizing coping strategies and managing his symptoms better. Client violent behaviors have dismissed. 2. Behavior: Client verbalized positive communication skills in the session. Client was observed helping mom and demonstrating responsible behavior around the house. Client affect was normal. Client understood to seek support at least once from an authority figure. Mom agreed to record 2-3 responsible behaviors by the client during the week that pertain to client meeting objective 1, 2, and 3. Mom agreed to start focusing and acknowledging client’s positive behaviors instead of his negative behaviors. Client shared how much he has been learning and what he enjoys best about having an in-home counselor. Client displays positive characteristics of his mental illness by controlling his impulses and considering QMHP directives. Client shared memories and funny stories, as he continued to show respect to his mom and counselor. Client attempted to use anger management skills to reduce aggressive communication with authority. Client was able to walk away and cool off correctly. Client and QMHP interacted well during the sessions. Mom was focused during the session and communicated his thoughts and feelings well. Client was mildly distracted by the noise coming from outside in the neighborhood. Client was directed to pay more attention and try to use the different sounds to stimulate his mind and relax in his seat, so that he will fully understand the activity and implement the right interventions. Client was encouraged to try his best to relax. Client is learning to maintain behavioral management at home without being redirected or corrected by QMHP or parent. The client appears to be functioning well in his crisis situations due to the increased support and supervision that he has received. Client learned to cope with stressors and eliminate defiance, which contributes to his success in day treatment. Due to patient’s inability to decrease ADHD symptoms and impulsive behaviors, client require intensive in-home counseling. 1. Intervention: QMHP facilitated one on one session with client to review being kind to others and not letting his emotions get the best of him. QMHP administered the session to enhance client’s ability to find a hobby or learn a new skill. QMHP went to the home for the purpose of meeting with client for individual session. QMHP engaged in conversation with client about upcoming weekend plans. QMHP asked client if he practiced his calming strategies for his home assignment last night. QMHP processed and reiterated with client about the rules in the home. QMHP assisted the client with understanding the expectations that have been established in the home and community. QMHP went over social skills activities with client to help him understand the importance of following rules. QMHP activity helped client state, demonstrate, or identify how to communicate her feelings. QMHP processed with client the thinking questions to each social skill activity. QMHP will help client develop healthy self-esteem by reducing level of anxiety and emotional reactions related to home and other independent functioning. QMHP praised client for being on task and following directions. QMHP processed client thoughts and feelings. QMHP engaged client in conversation regarding his recent behaviors, progressions, and setbacks. QMHP encouraged client to apply these social skills to when he goes back to school for the 20-21 year. QMHP informed client that we need friendships and positive relationships so that we learn how to give, accept, and receive constructive criticism and support from others. QMHP told client that our interpersonal relationships shape our minds and uplifts our spirits when we are sad or lonely. QMHP educated client that having a strong support system can uplift our mood, reduce stress and anxiety, improve our self-esteem, and hold us accountable for our actions. QMHP encouraged client to identify how to be kind to everyone he comes in contact with. QMHP praised client for the feedback during the session and showing more effort to contribute to discussion. 2. Intervention: QMHP spoke with mom in reference to her son’s treatment plan and advised them of any changes or concerns that may be present. QMHP provided parent with additional resources on client’s diagnosis and information that maybe useful for him at home. QMHP assisted client with learning new ways to express himself without feeling embarrassed or scared. QMHP engaged client to teach positive and appropriate anger management techniques. QMHP reminded client to utilize his calming techniques when he feels like he is getting ready to explode. QMHP processed with client how the calming techniques can make a difference on the way he perceives the world around him. QMHP acknowledged client for listening and paying attention during the session. Client responded well to praise. Client was receptive as QMHP demonstrated and defined the meaning of empathy. Client actively participated with QMHP as they discussed and processed empathy. Client demonstrated that he was able to process productive expressions of anger. Client displayed active behaviors in family setting. QMHP informed client that on our culture, genes, upbringing, education, gender, beliefs, and life experiences make us who we are. QMHP explained to client that we all have bad days. QMHP encouraged client to be kind to himself, his peers, and his elders. QMHP explained to client that people always remember how you made them feel. QMHP noticed client is making progress with expressing himself. QMHP made insightful comments which help client contribute to his part of the discussion. 1. Response: During the first part of the session, client’s mother sat and listened as the treatment plan goals and the plan of actions were read off to her and her son. Client’s parent agreed to all the terms and conditions and made no objections to the treatment plan as she signed it and shared her own questions and concerns for her son(s). Mom thanked QMHP for her patience and service with wanting to help her son do better in all aspects of his life especially at home living with his brother and no father figure. Client also followed along and answered questions on the topic. Client demonstrated a nonchalant attitude but displayed good eye contact and positive facial expressions throughout the entire session. Client displayed active listening skills during the session, as he nodded his head up and down and responded back to feedback to assure the counselor knew he was engaged in the discussion. Client does not seem to like losing privileges and other important things, as evidenced by him stomping around the house. Client communicated that he has implemented acquired skills to deal with his stress and anxiety. Client promised to stay focused with meeting his goals and objectives at home on a daily basis. Client knew how much it meant to his mom and other boys his age going through the same issues. Client participated and cooperated well with the social skills activities. Client was able to answer the thinking questions with assistance from QMHP. Client asked appropriate questions concerning the social skills activities and how it relates to everything that is going on in the world. Client implemented appropriate social interaction skills in front of mom. Client was observed and reported eliminating personal conflicts at home. Client utilized conflict management skills. Client exhibited techniques for appropriate self-expression and active listening. Client communicated positive self-talk and affirmations. Client was able to recognize personal strengths and abilities to perform better at home. Client smiled and transitioned to the next activity. 2. Response: The interventions were successful, as seen by client’s open and honest affirmations. Client reported that he is more kind to himself and others by being polite and courteous. Client was compliant and content without displaying hyperactive or impulsive behaviors and following along with the QMHP. Client was able to demonstrate the correct emotions while presenting appropriate manners towards the QMHP. Client reported that rules teach us how to listen and follow directions. Client reported that when he gets in trouble mom takes his electronics away and he cannot go outside or stay the night at his aunt’s house. Client admitted that this made him upset before, but he realized his mistakes in the past and plans to correct them. Client was receptive to the intervention as he was able to provide a response during the session. Client stated that he would walk away from the problem and allow himself to cool off first. Client shared that he tries not to blame others for his actions and choices unless he feels it is not his fault. Client appreciates his family for supporting him with all his needs and is thankful for the people that love and care about him. Client was able to identify examples of how to be kind and was very cheerful, at this time. Client was observed completing the therapeutic activity in a timely manner and displayed a positive attitude. Client expressed excitement, demonstrating mindfulness and seemed to be motivated to observe closely in social environments. Client implemented good communication skills by listening attentively and closely. Client displayed full participation during family activity. Client has improved with staying calm and utilizing relaxation skills in the home. 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 he was going to practice coping strategies and relaxation techniques in all aspects of his daily living routine in hopes that he will be a better person, son, brother, and friend.