1/31/2023 EnchantaVaughn Approved 1. Behavior: When QMHP arrived, client was not in a good mood. Client had a disappointed look on her face but switched moods once session started. Client communicated that she does not want to be in the house watching her little sister while her mom does hair when all of her friends are outside playing. Client stated that she locked herself inside her room so that she wouldn’t have to associate herself with anyone. Client expressed that she needed time and space to calm down. Client continues to show disrespectful manners, as well as, guarded behaviors in the home environment. Client communicated with QMHP that she cannot talk to her mother in the same way she can talk to her counselor and doesn’t want to talk to her about her problems. Client is afraid mom will judge her or yell at her. Client refused to listen to what anyone had to say. Client shrugged her shoulders, indicating she didn’t care. Client continues to express and elaborate on the negative relationship between her and others around her. Client continues to state that she doesn’t want any assistance or support with her behaviors or feelings and can handle it on her own. Client was upset but was able to recollect and focus on her therapy. 2. Behavior: Client expressed feelings of panic and distress throughout the day. Client agreed to walk away, count to 10, and think about positive affirmations when having meltdowns at home. Client agreed to practice listening skills at home and be more open with her emotions instead of shutting down and avoiding her family. As the client has been allowed to have greater choice regarding her services and providers, she 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. Client was receptive to the idea of practicing breathing technique and meditation strategies. Client is willing to keep working on more positive coping techniques so that she can deal with her feelings around her mom. Client appeared to be obtaining the information and showing more positive feelings. Client was supported for being honest. Client was given a 15-minute break to process her thoughts while mom and counselor discussed important information regarding her treatment plan. Client was cooperative and appeared to be learning a lot from today’s session. 1. Intervention: QMHP led the client through each therapeutic intervention. QMHP inquired about client’s day and what things is she doing to make it a good day. QMHP monitored client individualized behavior modifications in collaboration with her family. 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 her mom when she 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 provided redirection when needed and processed with client on what she needs to do to achieve ISP objectives. QMHP educated client about what she can do to make her daily activities more fun and interesting, such as reading her favorite book, drawing in a journal, stretching and closing her eyes and practice the mindful behaviors learned in previous sessions. 2. Intervention: QMHP motivated client to respond to exercise and express her feelings openly. QMHP cheered on client when she was able to let go of unwanted feelings and replace them with happy feelings. QMHP guided client throughout the activity to ensure she was paying attention. QMHP monitored effects of meditation and coping practices daily and documented her progress in her treatment chart. QMHP assisted with reducing anger-provoking situations through self-talk and role play scenarios in order to prevent escalation and dealing with anger assertively. QMHP continued to assist client with managing anger and frustration by reviewing and role-playing effective coping skills. QMHP helped client problem solve when she began displaying negativity towards herself and others. QMHP modeled proper positive behavioral expectations for the client to encourage additional layers of support and understanding of rules and expectations. Although client needs improvement, QMHP commended client on her efforts to maintain her ISP objectives as best as she could. QMHP observed client dismissing without incident and preparing for the night in a positive manner. 1. Response: Client admits when she is wrong and apologizes immediately. Client is more confident in the session, as evidenced by her assertive and proud tone when discussing parts of her day. Client is learning to calm down, think first, and respond without anger and frustration. Client continues to make progress with ISP objectives. Client transitions smoothly and safely to session area, displaying appropriate behaviors. Client is observed waiting for instruction. Client expresses good statements about her day saying she did her chores, used good manners, and was fair and polite to everyone in the house. Client have been doing a better job controlling impulsive and hyperactive behaviors, due to keeping her hands to herself, clean, and staying in designated area. Client is working on walking away and telling an adult before responding to anger provoking situations. Client understands that problem solving starts with thinking before acting. Client demonstrates problem solving by staying calm and using her senses. Client acknowledges expectations and reviews goals and objectives with counselor and parent daily. Client reduces sadness and finds more excitement in learning about her mental illness during this stressful time. 2. Response: Client displays good participation in session. Client exhibits appropriate behavior in the home, as observed during the role play activity. Client displays coping skills when faced with conflict due to deep meditation exercises. Client understands that sessions are a privilege and she have to show good work ethic and follow along with the interventions. Client is making progress with expressing her feelings and showing others respect and courtesy by talking with appropriate tone, initiating conversation with parent, and waiting for her turn to talk before blurting out loud. Client said she loves coloring activities and utilizes this to relax and stay focused. Client was honest about her wrong doing and is working to change those behaviors. Client was able to reevaluate herself and display a more positive attitude toward peers and authority. Client learned to look for similarities rather than differences in herself and others. Client did not run away from sharing her thoughts and feelings or get frustrated like she normally does during unexpected changes.