9/7/2023 EnchantaVaughn Approved Behavior: Client greeted her counselor with honor and respect. Client communicated that she was feeling good about herself since spending more time at home with loved ones. Client implemented appropriate conversation and was careful not to talk over the adult. Client was observed in the session on task and displaying excellent pro social behaviors (e.g. helping counselor during family activity, sharing her thoughts when needed, and volunteering to pass documents for review). Client was focused and attentive to instructions. Client was respectful to mom and sister who were in the house attending to other things. Client exhibited responsible behavior during session and exhibited mature behaviors that were supported and encouraged by her mom, as well as her aunt who comes by to visit often. Behavior: Client engaged in reflective thinking with mental health professional. Client displayed active listening skills in individual setting. Client was acceptive to feedback. Client expressed positive thoughts at this time. Client was respectful of in-home staff and presenting favorable actions, at this time. Client was observed asking and answering appropriate questions. Client exhibited excellent communication skills by being polite and patient creating a positive therapeutic atmosphere. Client was observed making good choices and avoiding negative ones. Client appeared to be in an ecstatic mood, as evidenced by her enthusiasm and positive expressions. Client maintains an excellent attitude, demonstrating a good rapport with QMHP. Client displays low symptoms of ADHD. Intervention: QMHP will give client a break at the beginning of the session. QMHP will encourage client to stay focused in the session and ignore external distractions. QMHP continued to monitor and receive an update on client’s relationship with mother and compliance to duties and expectations for client in the home and in the community. QMHP observed client complying with home rules and expectations. QMHP expressed gratitude toward positive interaction with mom and sibling. QMHP encouraged client to continue displaying positive behaviors. QMHP assisted client in monitoring her own behaviors in efforts to promote exercising self-control in focused areas such as respecting boundaries with others. QMHP encouraged client to keep doing a good job at home. Intervention: QMHP inquired about client’s afternoon activities and what she does when she finishes all of her work and chores. QMHP offered active listening skills. QMHP encouraged client to utilize positive self-talk as a means of decreasing anxiety and managing frustration when encountering difficult or challenging circumstances. QMHP talked to client about her confidence levels and how they can affect her day and self-esteem. QMHP praised mother for showing more consistency and efforts with assisting her daughter in understanding how to follow rules in the home and increase her social skills outside the home. QMHP assisted client in creating a space where she could release her thoughts and feelings whenever she didn’t want to share them with anyone. QMHP reminded client that each session is focused on helping her move forward with her goals. Response: Client was able to recognize personal strengths and abilities to perform better and help mom more around the house. Client expressed excitement when it was time to demonstrate her strengths in front of authority because she was confident and prepared. Client showed high level of participation in the session. Client is supportive of her family, as evidenced by her helping everyone in the home. Client was able to speak calmly and demonstrate her improved verbalization skills while conversing with mom. Client made insightful comments which contributed to discussion. Client was seen interacting well with counselor and parent. Client was observed working towards ISP goals. Client seemed to be enjoying the session and looked excited when transitioning to the next activity. Response: Client was seen completing individual assignments. Client appeared very relaxed and upbeat during exercise and needed no redirection. Client did not display any outbursts during the role play exercise. Client said she likes creative and artistic activities. Client agreed to follow instructions and finish her work. Client displayed good study and organizational skills. Client displayed an understanding of ADHD and its symptoms and causes. Client reflected on yesterday’s events. Client smiled and said thank you. Client displayed healthy self-esteem in home setting. Client exhibited techniques for appropriate self-expression and active listening. Client expressed a belief in self as being lovable and capable. Client demonstrated appropriate interpersonal skills, assertiveness, confidence in self and ability to problem-solve on her own.