2/9/2023 EnchantaVaughn Approved 1. Behavior: Upon arrival, client was observed displaying a displeasing attitude due to not wanting to come to her session. Client expressed she wanted to take a nap first. Client’s mom reminded her that if she didn’t attend to her therapy she would be in trouble. Client exhibited poor impulse control, as evidenced by her constantly moving around the room and being disorderly. Client required to be given 2-3 prompts prior to being sent to QMHP for further assistance. 2. Behavior: During this time, client was not productive or willing to participate in the provided therapeutic activity. Client was not receptive to redirection and ignored her counselor, continuing to act as if everyone was being mean to her for no reason. Client was upset and threw a tantrum attempting to get her way or get sent to her room on purpose, so she wouldn’t have to follow along with her therapy. Client remained off task for the remainder of the session, indicating she was in a downward mood. 1. Intervention: QMHP utilized empathetic listening skills as client expressed her understanding of stressful situation. QMHP provided age appropriate understanding of the situation and why she is there to help resolve any issues she has, including her having difficulty completing chores or assigned work. QMHP informed client that refusing to do her work is not acceptable and she should take small personal breaks involving deep breathing and stretching in her seat without initiating conflict in the home. 2. Intervention: QMHP isolated client from distractions to decrease disruptive behaviors and to reduce episodes at this time. QMHP will provide strategies for coping and self-control. QMHP encouraged client to be mindful of others personal space and knowing when to set boundaries for herself. QMHP encouraged client to refrain from displaying negative behaviors towards her mom, to talk calmly and express herself without aggression. QMHP encouraged client that tomorrow is a new day and she can do better. 1. Response: Client had one on one with QMHP. Client understands that her treatment plan is a behavior contract that will reflect her improvements and setbacks in the home. Client is reminded to tell her mom if she feels discouraged before starting unnecessary drama or lashing out and causing a scene in front of company. Although client has difficulty staying focused in the session sometimes, she understands a lot of the information taught in the session and has influenced her communication skills in the home, school, and community. 2. Response: Client was honest about her wrong doing and is working to change those behaviors. Client recognized her triggers and was able to identify common interests and similarities she and other ADHD recipients shared. Client understand that she is expected to act civilized and use her inside voice while inside and transition safely to session and to places in the community that are safe and appropriate for her mental health. Client said she was going to practice coping strategies and relaxation techniques in all aspects of her daily living routine.