2/9/2023 EnchantaVaughn Approved 1. Behavior: Upon arrival, client was observed in an upbeat manner. Client seemed very excited to see her counselor and initiated conversation right away. Client was observed cooperating with parent and displaying patience and respect. Client demonstrated responsible behaviors by sitting properly in her chair and waiting patiently for instructions. Client communicates positive self-talk when sharing her feelings. Client has been listening and following home rules, very attentive to activity, and careful not to talk over QMHP. Client demonstrates that she knows how to manage her emotions and have self-control without hyperactive and disruptive behaviors. Client was observed making insightful comments and engaging in family discussion. Client demonstrated excellent mannerisms. Client was focused, paying attention, and on task. Client displayed cooperative behaviors toward authority and appeared to be in a positive mood, as evidenced by her straight forward expressions and pleasant demeanor. Client was supported for increasing her involvement in social and recreational opportunities. Client continues to execute responsibility for her actions by making good choices and utilizing all strategies. Client was able to transition between activities without altercation and was supported for these behaviors. 2. Behavior: The interventions were viewed as successful. Mom reported that client has been doing well at home and continues to show improvement in school and managing her disorder. Client is beginning to recognize her triggers and stressors and have accomplished a lot independently. Client is able to process information that is important to her treatment plan and this has significantly improved her relationships and experiences in the home, virtual setting, and in the community. Client understands that going to therapy will help her maintain good behavior and deal with conflict. Client communicated that since being in service she has felt less aggravated and more capable of getting through the day. Client stated a lot of her fears have went away and she is more confident around her family. Client has developed increased social skills, and the benefits of this were reviewed. The client appears to be functioning well in her crisis situations due to the increased support and supervision that she has received. Client cooperated with counselor during role play and communicated that she understands how her past behaviors have negatively affected her. Client is supported for her authenticity. Client displayed good social skills while counselor reviewed material for upcoming session. 1. Intervention: QMHP conducted session following open discussion with client and parent by assessing her behaviors and mood. QMHP inquired about client’s current feelings and provided positive affirmations. QMHP processed client positive behaviors. QMHP assisted client in developing more social skills. QMHP probed client about talking with her mother about her feelings. QMHP commended client on utilizing coping strategies to increase her understanding of feelings and emotions. QMHP will help client develop healthy self-esteem by reducing level of anxiety and emotional reactions related to school, home, and other independent functioning. QMHP praised client for being on task and following directions. QMHP educated client about appropriate touch and personal boundaries. QMHP processed client thoughts and feelings. QMHP explored client’s responses and provided appropriate feedback. QMHP supported client making good decisions and having positive behaviors in the home. QMHP communicated with client and mother about client’s progression and possibilities of goals and objectives during continuation of services. QMHP encouraged client to practice relaxation and coping techniques in social/virtual environment, at home, and in the community. 2. Intervention: QMHP continued to engage with client and provided positive reinforcement as she participated in the psychological games presented to her. QMHP continued to elaborate on ways client can cope and manage stressors with these exercises. QMHP commended client for her participation and honesty. QMHP consulted with mother about increasing structure in the home to aid client in acknowledging the importance of operating and cooperating in the home setting. QMHP urged mother and client to participate in role reversal activity to aid mother and client to realize how to respond to and interact with each other. QMHP processed with client about what she learned from the games. 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 encouraged client to use her strategies and skills with peers, family, and teachers to support her with managing symptoms associated with ADHD. QMHP reminded client of her strengths and abilities. QMHP praised client for her efforts and being respectful to her mom. QMHP employed positive reinforcement when the client was able to achieve all of her goals listed on her service plan. 1. Response: Client informed QMHP that she was happy and excited to come to session. Client was able to cooperate and comply to rules and regulations due to positive influence within the home setting. Client implemented pro social skills successfully. Client was sociable and friendly in regard to the QMHP’s positive empathy. Client has presented herself in a responsible way and is making progress towards her goals and objectives. Client maintains good etiquette by sitting in her seat during instructed activity, raising her hand and asking appropriate questions, being respectful toward mental health professional, remaining quiet during quiet time and active during social time, listening to her mother, and modeling appropriate behavior in the home. Client responds well to the positive reinforcement, praise, and support provided by QMHP and is seen increasing self-esteem and confidence. Client utilized relaxation strategies. The client showed her gratitude for being able to release physical tension stating that she feels relaxed. Client is seen laughing and interacting well with her counselor. Client responded to feedback and shared some of her own experience with dealing with anxiety. 2. During the session at the home, mother expressed client’s behaviors have improved but she still has to remind client about remaining consistent with reacting positively when being reprimanded or redirected. Mother and client displayed good communication. Although mom is more stressed with the end of her pregnancy, she has cut back on work to spend more time with her daughter. Client responds well to praise and encouragemeResponse: Client demonstrated adequate progress heading into the second half of the session. Client was able to communicate with the QMHP without mother present. Client communicated that she felt safe and comfortable talking to the in-home counselor. Client acknowledged that she has not become angry and continued to smile and have a good time. Client expressed she was happy to finally have someone she can talk to about her feelings without feeling judged. Client was receptive and open to the interventions, as she was attentive and focus on the information and activities that were being processed without any difficulties. Client did not display any difficulties or complications in response to provided interventions. It was noted that the interventions were successful. Client appeared to have a clear knowledge of the interventions. Client smiled as she was affirmed for her mature and pleasant behaviors. Client was able to relax and regain and regulate her overactive behaviors throughout the session. Client was receptive and open, extending a healthy rapport back to QMHP. Client stated she had a clear comprehension of the purpose of session and her expectations in session. Client was compliant in today’s session.