11/1/2023 EnchantaVaughn Approved Behavior: QMHPA arrived to the residence of Kaila. Upon arrival to Kaila’s residence, Kaila presented a depressed mod with a flat affect evident by Kaila consistently speaking in a loud tone when communicating with QMHPA. QMHPA engaged Kaila in a discussion to determine why Kaila was in a foul mood. Kaila stated to QMHPA that she is just tired of a lot of things that she is surrounded by. QMHPA informed her that this session was going to address being able to identify her depressive symptoms manifesting in her daily functioning causing her mental illness management to become unstable. Intervention: QMHPA began the session by assessing Kaila’s emotional well-being. QMHPA addressed Kaila’s baseline mood utilizing validation and encouragement for her successful identification of her mood. QMHPA reminded Kaila of her ISP goals and the purpose of her ISP goals. QMHPA reiterated to Kaila the importance of Kaila being able to recognize and identify stressors that causes her inability to stabilize her mental health management and the importance of Kaila learning to assertively address any situations that contribute to Kaila’s inability to stabilize her mental illness. QMHPA suggested to Kaila that she re-think her decision of wanting to discontinue her psychotropic medications. QMHPA requested that he attends her next psychiatrist appointment. QMHPA utilized active and attentive listening as she discussed with QMHPA her frustrations with her mother and her boyfriend. QMHPA assisted Kaila with learning to recognize and verbalize hurt and angry feelings in open assertive ways. QMHPA assisted Kaila in becoming able to recognize needs and feelings and to express hurt and angry feelings as opposed to holding them in manifest in physical ways (sleeping, depression and withdrawal). QMHPA ended the session by provided Kaila with several ways to address her emotions and ability to recognize and respond to those emotions in healthy ways. Response: Kaila appeared to be receptive of QMHPA’s suggestions that were provided to her during the session. Kaila discussed with QMHPA that she was just excited about having to a counselor as she mentioned in the beginning of the initial session. Kaila stated to QMHPA that she has been very depressed and at times she don’t even know why. She stated to QMHPA that she think it is because she has dealt with so much in her life and she just gets to sit down and talk about everything that she has been through. She stated to QMHPA that she wants to not take her medication anymore because she don’t like the way that it makes her feel but she knows that she need the medication because if not she is going to go hurt someone. She stated QMHPA that her boyfriend and her mother gets on her nerves a lot and they cause a lot of the things that goes through her mind too. Kaila expressed to QMHPA that she was going to express her feelings more rather than holding them inside. Plan: QMHPA will educate Kaila on utilization of relaxation skills that consist of muscle relaxation, guided imagery, and slow diaphragmatic breathing. QMHPA will assist Kaila with coping and calming strategies to reduce depressive symptoms during individual sessions (1-2x weekly).