1/22/2023 EnchantaVaughn Approved 1. Behavior: QMHP met with client for in-home services and to check on how he was doing since the last visit. Client was present in the home during session. Client communicated he was in a good mood. Client was witnessed adhering to the rules and regulations in the home. Client explained that being in a pandemic made him feel sad, nervous, and grateful all at the same time. Client was polite and courteous to mental health professional while reviewing activity. Client interacted well with his family and displayed excellent leadership skills by setting an example for others by listening, paying attention, and sitting in his seat correctly. Client displayed his ability to use positive communication as he expressed his feelings and concerns. Client showed control over any intense angry feelings. Client seem to be heavily impacted by good role models and one on one support. Behaviors were maintained and managed at this time. Client displays the correct manners, saying please and excuse me when he had to ask a question. Client is seen conversing and responding well to feedback. Client was observed following rules and being compliant of the reinforcement provided by dad and QMHP. Client expresses gratitude and compassion toward his counselor for helping him and being there for him. Client exhibits high self-esteem and is observed encouraging himself to make good choices. Client says he feels good and is having a good day. Client enjoys receiving compliments and rewards for his hard work. Client remains on task and is observed following directions promptly. The family showed positive interactions during today’s session. The family interacted well with one another and spoke to each other calmly and effectively. 2. Behavior: Client was able to cope and relax in his environment and complete his assignment. Client was calm and patient and sitting appropriately in his seat without hyper activeness or impulsive behaviors, which were noticed by dad and QMHP. Client was well-behaved and stayed on task the entire time. Client was observed helping and displaying good sportsmanship. Client was praised for being a responsible person and for initiating his assistance. Client seems to be interested in working on himself, as evidenced by successfully completing the intervention and modeling good self-talk and affirmations. Client displayed positive social behaviors with his counselor. Client was monitored and observed interacting well with parent and staff. Client expressed a positive attitude while engaging in conversation with his step mom and dad. Client was seen cleaning trash off floor and waiting for directions to end his session. Parent communicated that client is allowed to attend family session every day after morning routine to accommodate his needs in order to meet his behavior expectations. Client was engaged in conversation and presented himself with a pleasant attitude. Client understands that everyone is there to help and support him and that it is okay to ask for help. Client was showing a positive attitude in all areas today. Client utilized the positive reinforcers provided by mental health professional by avoiding conflict and communicating positive thoughts. Client displayed good social behaviors, as evidenced by increased peer interaction and being a good example to his age group. Client displays age appropriate skills during one on one; avoiding conflict, staying on task and focusing on achieving his goals. The client was supported as he focused on the part of himself that wants to get better. Client expressed a cheerful mood at this time. Client was happy his counselor spent time with him today and walked her to the front door, waving goodbye and returning to family setting. 1. Intervention: Today’s interventions were focused on objectives 1, 2, and 3. QMHP discussed with dad about client’s involvement during their session and how much improvement is noticed so far. QMHP modeled how to show client more support. QMHP discussed ways to increase more positive coping mechanisms and how to display more positive behaviors. QMHP had one on one with client. QMHP explored positive behavior options he was exhibiting with client to support his willingness to continue to make good decisions and display appropriate behaviors in the home. QMHP processed client’s thoughts and feelings. QMHP inquired about evening routine. QMHP activity helped client state, demonstrate, or identify how to communicate his feelings. QMHP processed with client the thinking questions to each social skill activity. QMHP applauded client for being the bigger person. QMHP modeled language for client to use while contributing to discussion. QMHP provided simple non-verbal praises as client was observed displaying positive home behaviors. QMHP informed client of replacement behaviors in efforts to decrease attention seeking behaviors the client often is involved in. QMHP modeled appropriate ways for client to get positive attention from his family. QMHP inquired of clients’ current mood. QMHP educated and practiced with the client on using breathing techniques and other anger management skills to assist him with maintaining a calm spirit. QMHP assisted client in monitoring his own behaviors in efforts to promote exercising self-control in focused areas such as respecting boundaries with others. QMHP modeled proper positive behavioral expectations for the client. QMHP reiterated with dad the importance of maintaining a healthy relationship and rapport with everyone in the home. 2. Intervention: QMHP went over services, objectives, and goals. QMHP reviewed effective communication skills with client to improve the way he spoke to family members. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. QMHP provided praise when the client continued to display positive behaviors throughout the day, remaining on task and was very respectful to siblings, parent/guardian, and mental health professional. QMHP probed client in order to process and explore different perspectives related to his treatment plan. QMHP prompted client to express how he believes parents and children should treat each other. QMHP encouraged client to think twice before reacting negatively or aggressively in situations that may not need that level of reaction to be solved. QMHP used the basic listening sequence to clearly draw out the point of view that the client was feeling and get beyond his aggressive language and behaviors. QMHP implemented individualized behavior management techniques with client. QMHP processed with client about psychoeducational activity while assisting with directions. QMHP explained the importance of the activity. QMHP provided feedback to client in regard to questions asked. QMHP explored client’s responses and provided appropriate feedback. QMHP supported client making good decisions and having positive behaviors at home. QMHP observed client in his own space to determine if he required assistance. QMHP observed client complying with rules and expectations 1. Response: Client communicated thoughts and concerns about thinking positively at all times. Client expressed that he tries to think highly of himself. Client showed interest in building interpersonal relationships with peers and authority to increase support system. Client expressed positive self-talk, modeled positive behavior, and good communication skills during role play activity. Client learned to avoid negative and defiant behavior and comply to rules. Client was seen following directions. Client joined session to utilize and learn new interventions and strategies. Client expressed appreciation to QMHP by smiling and giving good eye contact. Client did not engage in any disruptive activities or behaviors. Client was able to maintain his composure when he was confronted with the potential for conflict. Client was observed engaging in several conflict resolution skills by walking away and telling an adult first. Client verbalized that he’s able to focus better when it is quieter and more peaceful. Client communicated positive thoughts about himself and others. Client was excited to see peers in his age group. Client remained soft spoken as he interacted with QMHP, mom and sister. Client participated in rapport building activity with QMHP. Client stated he was glad to be in therapy both at home because he’s learning a lot about himself and his family. Client has improved with staying in the home, following rules, and utilizing his breaks appropriately without needing to displaying attention seeking behaviors to get his way. Client has difficulty staying focused when distracted by others who are off task and has to be reminded to get back on track. Client responds well to praise and support. Client is acceptive of redirection. Client understands that his actions have consequences. Client is striving for a good report every day. 2. Response: During conversation, father expresses how proud she was of client and how far he has come since the beginning sessions. Client was happy to hear he was doing a good job and promised to continue to be good. Client was receptive to the education and training. Client gained knowledge about following directions the first time and being a good listener. Client demonstrated good social skills and ability to get along with others. Client expressed positive self-talk, modeled positive behavior, and good communication skills during role play activity. Client responded well to feedback, interacting well with everyone. Client agreed to behave at home more often. Client communicated a positive attitude when reviewing problem solving and self-control strategies. Client was cooperative and compliant. Client displayed appropriate social skills. Client was sociable and friendly in regard to the QMHP support. Client have adapted and is observed modeling appropriate behavior. Client wished he had more friends at home and school and plans to start building more relationships with his peers. Client was happy and in a good spirit throughout the entire 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 his ideas when answering questions during one on one. Client is making progress with expressing his feelings and showing others respect and courtesy by talking with appropriate tone, initiating conversation with peers, and waiting for his turn to talk before blurting out loud. Client did not display any outbursts during the role play exercise. Client learned to look for similarities rather than differences in others. Client demonstrated expectations and responded well to redirection from father and VACCD staff.