1/31/2023 EnchantaVaughn Approved 1. Behavior: Upon arrival, client was engaging in conversation with mother. Client appeared to be in a moderate mood, as evidenced by client smiling during conversation with mother. Client greeted QMHP welcoming counselor into his home. Client was very cheerful, indicating he was going to have a good session. Client displayed affection toward mom when she left the room. Client reflected on his day, the good and the bad. Client communicated that he spends a lot of time playing video games and playing outside with his brother now that school is over, and he gets to stay home more often. Client was excited to start the psycho educational activity. Client sat quietly and waited for instruction. Client demonstrated good conduct, adhering to home rules and making a good first impression. Client’s personality as cheerful, cordial, polite, and friendly, as he communicated openly with the QMHP in a mature and pleasant manner. Client displayed a kind hearted and caring attitude, as he was obedient and respectful towards QMHP. As the client builds rapport with QMHP he was seen listening and giving positive feedback. Client modeled appropriate behaviors as he communicated with the QMHP. Client modeled positive social and communication skills as he interacted with the QMHP. Client continued to show mature and responsible behaviors as he was able to identify what is causing his anxiety and how he is managing it. Client displayed his ability to use positive communication as he expressed his feelings and concerns. Client showed control over any intense feelings. Client later smiled as he prepared for worksheet activity. 2. Behavior: Client exhibits a good attitude transitioning into the therapeutic activity. Client was polite and attentive at this time. Client displayed interest in session by debriefing and answering appropriate questions. Client demonstrates a positive attitude and is seen participating in discussion and getting to know QMHP. Client was a little hyperactive at first but as time went by he became more open and relaxed. Client shared his experiences and hobbies. Client explained his needs and things he has difficulty with at home and asked if his counselor would help him. Client was happy to have a counselor during this time of need especially with all the distancing from his friends and community closings. Client expressed love and joy with supporting others and helping mom around the house. Client was focused and attentive during the session, as he remained seated on the couch without any difficulties or complications. Client showed empathy and consideration towards the QMHP, as he listened carefully to the information that was being processed with him during the session. Throughout the session QMHP reviewed and worked with client to continue to show respect as well as learning to develop empathy and exhibit the skill on a daily basis. Client exhibited excellent participation with in-home assignment and displayed a cooperative attitude toward his mother, communicating his feelings in an appropriate tone and manner. Client ended session with hugging QMHP and waving goodbye and returning back to his home duties. 1. Intervention: During conversation at the home, QMHP communicated with client and mother about client’s progression and possibilities of goals and objectives during continuation of services. QMHP also encouraged mother to point out possible stressors and/or irritations that client may trigger by behaving negatively. QMHP consulted with mother about increasing structure in the home to aid client in acknowledging the importance of operating and cooperating in the home setting. QMHP urged mother and client to participate in role reversal activity to aid mother and client to realize how to respond to and interact with each other. QMHP assisted client with recognizing his own personal strengths and how to apply them daily. QMHP expressed positive feedback when answering client questions and concerns about his mental illness. QMHP gave client the opportunity to open up and share his feelings. QMHP communicated active listening skills. QMHP educated client about sharpening his senses and utilizing problem solving techniques daily. QMHP encouraged client to be respectful to authority and peers. QMHP reminded client to build healthy relationships with his family and use each other as motivation. QMHP expressed gratitude and appreciation toward client for dealing with his feelings and recognizing when he is sad or upset. QMHP empowered client by emphasizing personal responsibility and the benefits of considering the consequences before acting. QMHP processed client's behaviors and feelings as it pertains to his stress and anxiety in the home. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement. QMHP will provide client with support and encouragement as needed. 2. Intervention: QMHP continued to monitor client’s relationship with mother and compliance to duties and expectations for the client in the home and in the community. QMHP encouraged client to use his strategies and skills with peers, family, and other relatives to support him with managing symptoms associated with ADHD. QMHP encouraged client to make good choices and to utilize self-calming techniques (i.e. counting and deep breathing) and processed with him that this behavior is acceptable and discussed actions and consequences. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. QMHP provided praise when the client continued to display positive behaviors throughout the session, remaining on task and was very respectful to his mom, brother, and counselor. QMHP established a schedule to prioritize and organize key daily activities. QMHP encouraged client to talk to his parents about both good and bad experiences at home and try to reevaluate the situation without extreme outbursts. QMHP will explore positive self-talk, use instruction modeling, and increase social communication skills with positive reinforcement role play activities. QMHP will monitor, observe, and redirect client behaviors as needed. QMHP will continue to build rapport with client. QMHP helped client manage ADHD symptoms and control impulses throughout the day by assisting client with gaining independence and increasing social/emotional awareness and communication. 1. Response: During the session at the home, mother expressed client’s behaviors have improved but he still has to remind client about remaining consistent with reacting positively when being reprimanded or redirected by an adult. Mother and client displayed good communication with each other. Although mom is more stressed with client actions and behaviors in the home, mom explains that she wants to spend more time with her sons each day. Client responds well to praise and encouragement and is seen paying attention to the activity and listening to QMHP. Client expressed positive thoughts about his strengths but seem to be struggling with his weaknesses. Client asked appropriate questions and talked about his challenges and hardships since being in quarantine. Client explains that his brother is aggressive and mean and always pick on him. Client was supported with listening and following directions despite stressful environment. Client processed his feelings with QMHP. Client engaged in self-reflection. Client reflected about his experiences in the home. Client practices mindfulness with 5 senses (i.e. listening, seeing, smelling, tasting, and movement). Client is observed being courteous and polite and showing excellent manners by saying please and thank you. 2. Response: Client responded well to review and was confident he can meet ISP objectives. Client communicated positive affirmations and self-talk. Client stated he is tired in the morning because he goes to bed late. Client understands it is his responsibility to prepare himself for each day. Client acknowledges that he has to be more respectful to his mother and brother before expecting to be treated fairly. Client modeled appropriate behavior in the therapeutic session by focusing on his goals. Mother states to QMHP that he has considered implementing a minor schedule for client to assist him with his completion of chores in the home, including but not limited to work assignments provided by client’s school. Mother mentions that schedule assists her as well and allows her to remain focused on completing individual tasks without negative reactions. Mom continues to motivate client to be more independent in order to prepare for the next day. Client utilized breathing and relaxation techniques to manage symptoms and behaviors associated with ADHD. Client was calm and displayed good eye contact and posture. Client stayed seated, despite having to go to the restroom or get a drink of water. Client is very inquisitive asking questions regarding his disorder and talking about his day. Client displayed appropriate behaviors and ended session on a good note.