1/30/2023 EnchantaVaughn Approved 1. Behavior: Upon arrival, client was seen being polite and courteous to his family. Client greeted the QMHP with love and respect. He also shared that he was excited for the activity today and couldnât wait to show his mom how much he has been learning. Client also shared that he wanted to take a nap because he had a long day. QMHP focused session on explaining his treatment plan and also having a calming strategy to engage in before starting the activity. Client was polite and positive throughout the entire session. Client displayed good eye contact. Client did not talk over QMHP like he normally does. Client exhibited an appropriate attitude. Client was calm and patient and sitting appropriately in his seat without hyper activeness or impulsive behaviors, which were noticed by mom 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 asked mom to join him so that he could see how far he has come since first meeting his counselor. Mom was proud of client for opening up and sharing his personal feelings with his counselor. Client openly discussed his feelings about his current state and how he feels. Client appeared to be in a good mood as evidence by him participating in family activity without conflict. Client remained on task and in cooperation with home rules. Client was not involved with any incidents today and was supported by parent and staff. 2. Behavior: Client conducted himself in a very well-thought-of manner and followed all directions during session. Client made constant eye contact with authority during the session. Client was well dressed and groomed through the session. Client was receptive to the idea of finding more activities that were fun for him but still incorporated therapeutic skill sets. Client and mother interacted well with each other during the session. Client knows what is expected of him and is trying to make better choices. Client verbalizes positive feelings about himself but recognizes areas he needs to work on. Client smiled and hugged QMHP. Client was observed in his seat and raising his hand during the activity. Client presented a good attitude throughout the session. Client appeared to be in a good space and dealing with his personal challenges one day at a time, as reflected in his growth and new habits. Client talked a lot about the good things that happened today and less about things that didnât matter. Client displayed good participation and communication throughout the session. Client seemed to be in a calm mood, as evidenced by his positive expressions and relaxed demeanor. Client displayed appropriate social behaviors in the home. Client was praised for having a wonderful end to his day and encouraged to keep up the good work. Client was seen displaying positive social behaviors, working well with others and actively engaged without causing disruptions. Client appeared to be in a content mood, as evidenced by his straight facial expressions and positive body gestures. Client looked very focused and attentive during the session, as evidenced by his productive and cooperative manners. 1. Intervention: QMHP will implement a routine that will encourage client to be responsible and promote self confidence in academic and social settings. QMHP reflected with client on his day, reviewing both good and bad experiences. QMHP processed with client, "what would you do different tomorrowâ. QMHP encouraged client to have a good evening. QMHP supported client with displaying positive social interactions with peers and authority. QMHP reinforced appropriate coping skills in the home. QMHP processed client positive responses and challenged client to maintain appropriate behaviors throughout the entire week. 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 introduced concept of nonverbal communication cues in efforts to review the expected behaviors or results to the nonverbal cue. QMHP continued to establish a positive supportive relationship with client. QMHP offered simple suggestions to the client for behaving appropriately in the home and community and encouraged client to practice the positive behaviors at school too. QMHP reviewed several strategies for conflict resolution and positive social behaviors with client in efforts to increase clientâs awareness. The client was encouraged to use good judgement, and respect authority figures. QMHP provided client with a release of energy by walking to get a drink of water to help him relax and open up more. QMHP provided simple praises to client for his commitment to his progress. 2. Intervention: QMHP completed another psycho-educational activity with the client that focused on controlling his impulses. QMHP inquired about clientâs afternoon activities and what he does when he gets home every day. QMHP offered active listening skills. QMHP monitored client individualized behavior modification through collaboration with mother. 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 mom the importance of maintaining a healthy relationship with his peers by allowing client to make new friends and be his own person, without feeling he has to fit in with the others who are not displaying good behaviors or being nice. QMHP monitored clientâs individualized behaviors while socializing with his peers. 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. QMHP provided strategies such as positive reframing. QMHP assisted client with practicing reframing negative thoughts with more positive thoughts in efforts to reduce impulsive reactions to situations that usually trigger the client's negative expressions. Client was able to reduce physical overactivity and become more attentive in session. QMHP discussed with the family one goal they believe they need to work on individually and as a family. QMHP had each member write down goals and discussed through brainstorming and creating a goals chart on how to achieve each one. 1. Response: Client responded positively to the routine of responsibility and self-confidence in therapeutic setting. Client communicated positive affirmations and self-talk during initial conversation with QMHP. Client smiled as he saw QMHP's positive gestures. Client was able to process making good choices with QMHP and his mother. Client listed 3-4 behaviors that he was going to utilize in efforts to remain positive behaviors. Client appeared to be receptive to receiving positive reinforcement from his mother as demonstrated by his smiling and inviting body language. The frequency and intensity of the client's defiant affect decreased. Client shared some of the things he does at home to help him relax. Client stated he loves playing outside but dislikes getting dirty. Client participated in reviewing key concepts on his mental illness and how to manage the symptoms. Client showed good understanding of what it means to be respectful, encouraging, mindful, and fair to others. Client understands that problem solving starts with thinking before acting. Client demonstrates problem solving by staying calm and using his senses. Client acknowledges expectations and reviews goals and objectives with counselor and parent at the beginning of each session. Client displays good social behavior, as seen sharing and taking turns. Client implemented the positive reinforcement provided by his counselor and was able to stay motivated and enjoy his day. Client exhibited good manners after earning incentive for his hard work. Client focused on things he is good at and loves to do at home in order to stay motivated in the school/community setting and make something out of himself. Client did a good job ignoring distractions and maintaining appropriate behavior in the home. Client administered positive behavioral expectations, reducing ADHD. 2. Response: The interventions were noted successful and making a difference in his life, as the client displayed new habits and routines. Client communicated positive thoughts about himself and others. Client was excited to see peers in his age group. 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 in the program 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 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 and in the community because heâs learning a lot about himself. Client was displaying respectful, non-aggressive behaviors in the home. Client expressed positive thoughts about himself. Client stated he didn't need help with anything at the moment but would tell an adult if he needs help. Client communicated by nodding and exhibiting good eye contact. Client verbalized positive feelings about goals and objectives.