3/6/2023 EnchantaVaughn Approved Behavior: Client made good constant eye contact and was very attentive during the in-home hours. Client was well dressed and groomed displaying excellent hygiene and appearance. Mother reports client continues to struggle with being able to commucniate with her as well as others her feelings which causes issues within the home setting. Behavior: Client was observed in her seat and raising her hand during the activity. Client presented a good attitude throughout the session. Client continues to struggle with being discuss her feelings with her mother as well as her not being able to control her aggressivness. Intervention: QMHP had one on one with client. QMHP will conduct a one on one to debrief and talk about daily behaviors. 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. Intervention: QMHP provided client with an alternative activity instead of being obligated to talk about her feelings. QMHP provided guidance on alternative behaviors and clear instruction on the alternative behavior. QMHP introduced concept of nonverbal communication cues in efforts to review the expected behaviors or results to the nonverbal cue. QMHP had client write down her short-term goals and discuss through brainstorming and creating a goals chart on how to achieve each one. QMHP monitored client’s individualized behaviors while communicating with her family and interacting with her peers. QMHP reinforced appropriate coping skills in the home and in the community. QMHP provided support and encouragement to ensure goals and objectives are met. Response: Client had one on one with QMHP to reflect on her day. Client communicated positive affirmations and self-talk, stating positive thoughts about others when asked about her interpersonal relationships. Client was excited to share things she enjoys and couldn’t wait to implement them during the session. Client displayed positive expressions and maintained good tone when communicating with QMHP. Client was respectful and polite, utilizing acquired skills provided by QMHP to share her ideas when answering questions during one on one. Client remained cooperative and compliant while waiting for directions on what to do next. Client displayed appropriate social and emotional skills. Client was sociable and friendly in regard to the QMHP support. Client have adapted and is observed modeling appropriate behavior in the home. Response: Client was observed displaying respectful, non-aggressive behaviors in the home as mom and QMHP had a conversation. Client exhibited good manners after earning incentive for her hard work and completing the activity. Client was happy and in a good spirit throughout the entire session. Client stated she didn't need help with anything at the moment but would tell an adult if she needs help. Client communicated by nodding and exhibiting good eye contact. Client verbalized positive feelings about goals and objectives. Client stated she was glad to be in therapy both at home and in school because she’s learning a lot about herself.