2/6/2023 EnchantaVaughn Approved 1. Behavior: It was noticed upon arrival, client was in a silent and secluded mood, as evidenced by her standoffish demeanor and withdrawing from the session. Client remained quiet until her mom told her she wouldnât be able to go outside if she didnât participate in her therapy. Mom reminded client that it is important to utilize her services as much as possible so that she can learn to decrease symptoms associated with her mental illness. Client was a little aggravated at this time but decided to switch moods. Client described that she worries about issues related to personal safety, health, education, and family, among other things. Client communicated that she didnât feel like having session today because every time she catches up on her work and chores she never gets a chance to relax without being expected to follow instructions. Client said she was tired and wanted to take a quick nap. Client was prompted to try her best to get through the session and to relax and pay attention, so she doesnât miss important information related to her case. Client was assured that the activity only required her to listen. Client was attentive and followed along with the simple task. Client displayed positive facial expressions and appeared to be retaining the information discussed by QMHP. 2. Behavior: Client cheered up and decided to do her best and challenge herself so that she could finish the session without complaining or falling asleep. Client communicated positive attitude and engaged in activity without frustration or being distracted by external stimuli. Client gave really good feedback and was responsive to all instructions given to her. Client was given praise and reinforced for participating in the session and developing self-determination skills. Client continues to display appropriate social skills in therapeutic setting. Client demonstrated ability to multi task by working independently and helping her mom when she needed. Client showed she is capable of exhibiting responsible behavior at home by being fair and showing compassion. Client demonstrated that she was aiming to meet her objectives today, as evidenced by her determination and carefree spirit. As the QMHP examined and assessed clientâs personality, it was noticed that she was compassionate and sympathetic towards the thoughts, feelings and needs of the QMHP, ending session with a positive attitude. 1. Intervention: QMHP collaborated with mom regarding daily behaviors and performance in the home. QMHP had one on one with client. QMHP initiated a rapport building conversation with client in efforts to learn more of her likes and dislikes as well as triggers to negative behaviors listed on her ISP. QMHP will review key concepts of being a responsible child in the home. QMHP will educate client about being respectful, encouraging, mindful, and fair to peers and authority while making good decisions in the home. QMHP will teach client necessary coping skills to decrease impulses. QMHP will brainstorm strategies with client and encourage self-monitoring. QMHP will provide mediation and relaxation techniques, as well as, simple praises and encouragement to continue the positive behaviors she was exhibiting. QMHP provided support and encouragement. QMHP modeled pro-social behaviors for client to strengthen her understanding of how to conduct herself in the home. QMHP commended client on utilizing coping strategies to increase her understanding of feelings and emotions. QMHP provided guidance on alternative behaviors and clear instruction on the alternative behavior. QMHP provided positive feedback when client engaged in the more appropriate behavior. 2. Intervention: QMHP engaged the client in a role reversal exercise and required the client to think about her goals. QMHP explored positive self-talk, used instruction modeling, and increased social communication skills with positive reinforcement role play activities. QMHP reviewed and gave feedback regarding ADHD and its causes and affect toward clientâs well-being and emotional functioning. QMHP monitored, observed, and redirected client behaviors as needed. QMHP monitored client individualized behaviors in collaboration with parent, herself, her peers, and environment. QMHP encouraged client to make good choices and to avoid negative thoughts about herself. QMHP processed client positive behaviors. QMHP assisted client in developing more social skills. QMHP inquired about possible challenges client can experience with applying this skill. QMHP provided positive feedback. QMHP reflected on client goals and objectives. 1. Response: Client had one on one with QMHP to reflect and process feelings about her day. Client communicated negative affirmations and self-talk. Client shared some of the things she does at home to help her stay calm. Client participated in reviewing key concepts related to her mental illness. Client showed good understanding of what it means to be mindful and fair to others. Client is observed correcting her mistakes and making good choices in the session. Client was able to utilize coping skills to eliminate stressors and unwanted feelings. Client displayed self determination to stay focused and pay attention in session. Client verbalized positive feelings about building relationships at home and in the community. Client responded in a pleasant manner acknowledging the positive reinforcement that the QMHP provided. As the client developed understanding of academic expectations, she reported increased satisfaction and function. Client was able to demonstrate fairness and kindness to peers and authority. Client provided several scenarios for QMHP to model positive prosocial behaviors within the home setting. 2. Response: Client discussed mental illness and its causes with mom and QMHP. Client communicated that she gets bored easily and is having challenges with completing her work at home and needed help staying focused. Client verbalizes positive feelings about herself but recognizes areas she needs to work on. Client exhibited safe behaviors. Client was able to reevaluate herself and display a more positive attitude toward peers and authority. Client has become more involved in age appropriate social activities and was given positive reinforcement for these choices. Client demonstrated expectations and responded well to feedback. Client reported a decreased stress level due to her modulation of social contact, and the success of this was reviewed. Client responded well to feedback, interacting well with others. as evidenced by the client smiling and saying thank you. Client displayed positive self-talk, ability to follow instructions, role play of appropriate way to act in school, increased communication and exhibiting the positive reinforcers that were provided by QMHP.