1/31/2023 EnchantaVaughn Approved 1. Behavior: Client appeared to be in a delighted mood, as evidenced by his ability to stay focused and complete his work on time. Client transitioned to pm activities in a good mood, displaying excellent leadership skills by leading the session and taking charge of his actions. Client was reported to be having a good evening by his mother. Client displayed positive behaviors, despite distractions around him. Client received permission from his counselor to take a break after he completes the activity. Client responded with positive gestures and continued following along with each prompt. Client appeared to be motivated by positive encouragement while being praised for his hard work. Client said thank you and prepared to answer questions regarding his mental health. Client utilizes his writing journal as a coping tool to stay calm and collected. Client communicated with his counselor that he was proud at everything he has accomplished even if some days he feels defeated. Mom was happy client was being respectful and expressed joy for his positive behaviors. Client acknowledges his objectives and made a commitment to achieve them daily. 2. Behavior: Client was polite and courteous to mental health professional while reviewing activity. Client displayed great participation skills in all his home activities. Client interacted well with his family and displayed excellent leadership skills by setting an example for others by listening, paying attention, and sitting in his seat correctly. Client displayed his ability to use positive communication as he expressed his feelings and concerns. Client showed control over any intense angry feelings. Client seem to be heavily impacted by good role models and one on one support. Behaviors were maintained and managed at this time. Client displays the correct manners, saying please and excuse me when he had to ask a question. Client is seen conversing and responding well to feedback. Client was observed following rules and being compliant of the reinforcement provided by mom and QMHP. Client was acceptive of feedback provided by QMHP. Mother expressed client had a good turn around and is happy to see him accomplishing his goals each day. Client appears to be content and stable mood, as observed by positive and calm behaviors. Client displayed age appropriate skills and impulsive, hyperactive behaviors were not present as the session came to an end. 1. Intervention: QMHP discussed with mom about client’s involvement during their session and how much improvement is noticed so far. QMHP modeled how to show client more support. QMHP discussed ways to increase more positive coping mechanisms and how to display more positive behaviors. QMHP had one on one with client. QMHP explored positive behavior options he was exhibiting with client to support his willingness to continue to make good decisions and display appropriate behaviors in the home. QMHP processed client’s thoughts and feelings. QMHP inquired about evening routine. QMHP assisted client with problem-solving. QMHP provided client with feedback. QMHP provided client with positive reinforcement. QMHP educated client about using good manners in the home and offering alternative methods and suggestions to model appropriate language that client should use instead of speaking in an ill-manner, aggressive, provocative way. QMHP modeled language for client to use while contributing to discussion. QMHP provided simple non-verbal praises as client was observed displaying positive home behaviors. 2. Intervention: Today’s interventions were focused on objectives 1, 2, and 3. QMHP went over services, objectives, and goals. QMHP engaged the client in a role reversal exercise and required the client to think about his goals for the future. QMHP activity helped client state, demonstrate, or identify how to communicate his feelings. QMHP reviewed effective communication skills with client to improve the way he spoke to family members. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. QMHP commended client on utilizing coping strategies to increase his understanding of feelings and emotions. QMHP assisted client in monitoring his own behaviors in efforts to promote exercising self-control in focused areas such as respecting boundaries with others. QMHP modeled proper positive behavioral expectations for the client. QMHP reiterated with mom the importance of maintaining a healthy relationship and rapport with everyone in the home. QMHP provided praise when the client continued to display positive behaviors throughout the day, remaining on task and was very respectful to siblings, parent, and mental health professional. 1. Response: Client joined session to utilize and learn new interventions and strategies. Client expressed appreciation to QMHP by smiling and giving good eye contact. Client was receptive to the recommendations that he received from his counselor as evidenced by him providing active feedback and communication during conversation. Mother reports that client has been more consistent with imposing consequences in the home in particular when client experiences difficulties in home/social settings. Client was receptive to the interventions, as evidenced by his cheerful expressions. Client demonstrates leadership skills by helping others in the home. Client communicated being home was a positive place for him compared to his out of home environment. Client displayed high ambition and was very productive, despite distractions. Client discussed mental illness and its causes as a family. Client displayed interest in learning about ADHD. Client has become more involved in age appropriate social activities and was given positive reinforcement for these choices. 2. Response: Client did not display any outbursts during the role play exercise. Client showed interest in building interpersonal relationships with peers and authority to increase support system. Client expressed positive self-talk, modeled positive behavior, and good communication skills during role play activity. Client remained soft spoken as he interacted with QMHP, mom and siblings. Client stated he was glad to be in therapy both at home because he’s learning a lot about himself and his family. Client has improved with staying in the home, following rules, and utilizing his breaks appropriately without needing to displaying attention seeking behaviors to get his way. Client learned to avoid negative and defiant behavior and comply to rules. Client was seen following directions. Client gained knowledge about following directions. Client have adapted and is observed modeling appropriate behavior. Client is making progress with expressing his feelings. Client was happy to hear he was doing a good job and promised to continue to be good. Client was receptive to the education and training.