2/3/2023 EnchantaVaughn Approved 1. Behavior: During today’s therapy appointment, client displayed a welcoming demeanor when he saw his counselor come inside the house. 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. The client was appropriately dressed for the day. The family seemed to be getting along and having a good day so far. During the session the client was alert and focused. The client’s behavior was acceptable as he was respectful and cooperated with the counselor when prompted or redirected. Incidents of recent anger outbursts by the client were processed and alternative, adaptive ways to express that anger were reviewed. 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 session. Client was attentive and followed along with the simple task. Client communicated positive attitude and engaged in activity without frustration or being distracted. 2. Behavior: Client was given praise and reinforced for participating in the session and developing self-determination skills. Client demonstrated ability to multi task by working independently and helping his mom when she needed. Client showed he is capable of exhibiting responsible behavior at home by being fair and showing compassion for everyone in the household. As the client has been allowed to have greater choice regarding his services and providers, he has been more motivated in treatment. Client exhibited appropriate social skills and team work during psycho educational activity. Client displayed a good attitude and was very respectful in the session, not interrupting counselor or being disruptive when it wasn’t his turn to talk. Client did not have to be directed on sharing or waiting his turn, and QMHP praised him for his excellent behaviors. Client was cooperative and appeared to be learning a lot from today’s session. Client demonstrated that he was aiming to present a decrease in problematic behaviors, as evidenced by his determination and carefree spirit throughout the session. Client was receptive to feedback and verbalized good thoughts during the session. 1. Intervention: QMHP monitored client individualized behavior modifications in collaboration with his family. QMHP motivated client to respond to exercise and express his feelings. QMHP offered active listening skills. QMHP provided client with encouragement to demonstrate the positive behaviors and expectations they had been talking about. QMHP encouraged client to communicate to his mom when he needs help. QMHP praised client for staying on task. QMHP complimented client for utilizing acquired skills, paying attention, and focusing on the importance of the assignment. QMHP supported client displaying positive social interaction with peers and authority. QMHP educated client about what he can do to make his daily activities more fun and interesting, such as reading his favorite book, drawing in a journal, stretching and closing his eyes and practice the mindful behaviors learned in previous sessions. QMHP modeled proper positive behavioral expectations for the client to encourage additional layers of support and understanding of rules and expectations, as well as, positive pro-social behaviors for client to strengthen his understanding of what to do in session, in the home, and in the community. 2. Intervention: QMHP reviewed and gave feedback regarding ADHD and its causes and affect toward client’s well-being and emotional functioning. QMHP observed client following directions and completing at home tasks with no prompting or complaining. QMHP observed client displaying positive social interaction with siblings by sharing and playing safely. QMHP engaged the client in a role reversal exercise and required the client to think about his goals. QMHP commended client on utilizing coping strategies to increase his understanding of feelings and emotions. QMHP provided positive feedback when client engaged in the more appropriate behavior. 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. QMHP encouraged client to make good choices and to avoid negative thoughts about himself. QMHP processed client positive behaviors. QMHP assisted client in normalizing the changes that are occurring in the community. 1. Response: Client exhibited a positive attitude toward mom and counselor. Client verbalizes positive feelings about himself but recognizes areas he needs to work on. Client smiled and continued to give QMHP his undivided attention. Client was observed in his seat and raising his hand when he wanted to ask a question. Client interacted well in the session and demonstrates good team building skills. Client displays good attitude by saying “thank you”. Client did an excellent job by showing interest in the session by asking appropriate questions. Client admits when he is wrong and apologizes. Client is more confident in the session, as evidenced by his assertive and proud tone when discussing parts of his day. Client have been doing a better job controlling impulsive and hyperactive behaviors, due to keeping his hands to himself and staying in designated area. Client acknowledges his expectations. Client reduces sadness and finds more excitement in learning about his mental illness. Client is learning to calm down, think first, and respond without anger and frustration. 2. Response: Client displays good participation in session. Client exhibits appropriate behavior in the home, as observed during the role play activity. Client asked appropriate questions concerning the activity. Client implemented appropriate social interaction skills. Client displays good social behavior throughout the session, as observed and supported by mental health professional. Client is reported building healthy relationships and performing a lot better emotionally and verbally. Client made insightful comments which contributed to discussion. Client displayed good study and organizational skills. Client was observed complying to authority requests and demands the first time they are given. Client expresses good statements about his day saying he did his chores, used good manners, and was fair and polite to everyone in the house. Client responded in a pleasant manner acknowledging the positive reinforcement that the QMHP provided. Client has implemented the correct behaviors in session toward in-home staff. Client continues to make progress with ISP objectives.