1/25/2023 EnchantaVaughn Approved 1. Behavior: During the visit, client was witnessed displaying appropriate socializations in the home. Client spoke to QMHP in a happy tone saying hello. Client presented with clean face and clean clothes. Client appeared to be ready for his session. The home appeared organized and well maintenance. Everyone wore masks and demonstrating social distancing during the appointment time. Client was able to contain impulsive actions. Client was observed having positive interactions with her family. Client was supported for her maturity and independence and interacting well with mom and sister. Client was excited to see her counselor and continued playing safely in the home. Client demonstrates that she is capable of utilizing effective coping skills and can calm down on her own without relying on authority to direct her. Client was assisted with creating and making new ideas in order to motivated her while completing her chores. Client appears to be content and stable mood, as observed by positive and calm behaviors. Client displays impulsive and hyperactive behaviors ( last occurring on yesterday). 2. Behavior: Client was able to transition to her therapeutic activity in a good mood. Client displayed full participation and did not complain or give up easily. Client was engaged and focused, indicating she was intrigued by what she was learning and discovering about herself. Client was observed being courteous and polite. Client was encouraged to keep being kind to others. Client demonstrated excellent manners at this time. Client displayed great participation in all of her home activities. Client still displays aggressive actions ( last occurring on yesterday) , but is becoming less aggressive around peers and authority, as monitored and reported in the home. Client verbalizes positive communication toward QMHP and exhibits excitement for each therapeutic activity introduced to her. Client was acceptive of feedback provided by QMHP. Client was open minded about receiving additional help and attending session. Client have come along way behaviorally since starting services and is recognized by VACCD staff for this accomplishment. Client acknowledges her progress and states she wants to continue to make a good impression on the people that love and support her. Mother expressed client had a good day and is happy to see her accomplishing her goals. 1. Intervention: QMHP facilitated a family discussion to talk about common mistakes children with ADHD make and how she can make better choices. QMHP reviewed expectations. MHP encouraged client to continue displaying age appropriate behavior, and the benefits of this will be updated in her charts for improvement. QMHP conducted a review of previous week interventions regarding mindfulness and solution focused. QMHP assisted client with problem-solving in a safe and calm way. QMHP provided client with positive feedback. QMHP educated client about using good manners at home and offering alternative methods and suggestions to model appropriate language that client should use to ask for things or to get someone’s attention. QMHP utilized empathetic listening skills as client expressed her feelings. QMHP processed client’s responses and gave appropriate feedback. QMHP helped client discover positive outlets of expression and using creative aides, such as music, art, paint, or coloring. QMHP explored positive self-talk, instruction modeling, and social communication skills with positive reinforcement during role play activities. 2. Intervention: QMHP provided client with an incentive for her excellent manners during assigned activity. QMHP explored the client’s capability to cope with her stressors and to cooperate. QMHP modeled communication and conduct during psycho educational. QMHP assisted client with finding and utilizing necessary resources. QMHP verbalized the awareness that all people are unique, learn differently, and have various strengths and weaknesses. QMHP provided positive gestures to encourage client to verbalize positivity with peers and authority. QMHP enhanced food management skills by encouraging client to eat healthy snacks at home as opposed to junk food/candy. QMHP expressed understanding of self-care and personal hygiene. QMHP offered praise and positive reinforcement to enhance self-esteem and sense of achievement. QMHP probed sense of empowerment by communicating positive self-talk. QMHP enhanced knowledge of a consistent daily routine. QMHP collaborated with mother in regard to home rules and regulations, behavior management, effective teaching practices, role playing exercises, and an appropriate incentive system to ensure client needs were being met. 1. Response: The client is observed and supported with doing the right thing. The client was able to identify interests and similarities displayed as a mental health client. Client was respectful during family discussion, avoiding interruption or talking over authority. Client avoids negative language (i.e. without using profanity, sexual comments, or aggressive words). Client has improved with staying productive and utilizing her breaks appropriately without needing to display attention seeking behaviors to get her way or to try to get out of doing work. Client is observed problem solving on her own and handling her emotions appropriately. Client avoids meltdowns and is seen cheerful and energetic. Client responds well to praise and support increasing self-esteem and confidence. Client utilized relaxation strategies. Client showed good understanding of what it means to be respectful, encouraging, mindful, and fair to others. The client showed her gratitude for being able to release unwanted tension within the home environment. Client has improved with staying in the home, following rules, and utilizing her breaks appropriately without displaying attention seeking behaviors. 2. Response: Client engaged in self-reflection and reflected on her day, the good and the bad. Reinforcement was provided to client during psycho educational. The client stated that she can be good and told QMHP that she will do her best to follow directions and keep her hands to herself. Client demonstrated how to verbalize her feelings without yelling and being aggressive. Client did not display any outbursts during the session today and was applauded for her good behavior. Client was supported interacting well with her family. The client responded in a positive manner acknowledging the positive reinforcement that the QMHP provided. Client was able to cooperate and comply to rules and regulations due to positive family influence. Client implemented pro social skills successfully. Client attends her therapy and has completed all psycho educational activities without giving authority a hard time. Client appeared to be calm after the intervention. Client demonstrated more acceptable responses, avoiding anger provoking situations in the home and community. Client has presented herself in a responsible way and is making progress towards her goals and objectives.