2/1/2023 EnchantaVaughn Approved 1. Behavior: During the in-home visit, client was observed having appropriate conversation with his family and preparing for his therapy session. Client was observed asking and answering appropriate questions. Client exhibited excellent communication skills by being polite and patient creating a positive therapy atmosphere. Client was observed making good choices and avoiding negative behaviors. Client appeared to be in an ecstatic mood, as evidenced by his enthusiasm and positive expressions. Client was seen displaying appropriate social interactions in the session. Client maintains an excellent attitude, demonstrating a good rapport with QMHP. Client continued to express positive feelings and demonstrate positive behavior. 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 others to make good choices. Client appears to be calm and relaxed after today’s intervention. Client says he feels good and is having a good day. Client is observed practicing interventions without no complaints and having fun in the home. 2. Behavior: Client engages well, communicating positive affirmations in session. Client expressed positive thoughts about his day. Client stated that he did good in school and was given a compliment by his teacher. Client communicated that he loves getting compliments and being rewarded. Client expressed that he finished all of his work on time and spent his free time playing with his brother and sister. Client exhibits great participation, following rules and expectations appropriately. Client was supported for increasing his involvement in social and recreational opportunities. Client continues to execute responsibility for his actions by making good choices and utilizing all strategies in session today. Client was cooperative and polite, presenting safe behaviors. Client finished his therapy assignment without distractions. Client maintained appropriate behavior throughout the session. As the client has increased his verbalizations of emotions, he focused onto his feelings that were motivating and uplifting. Client was reminded to think positive and continue to utilize coping strategies and relaxation techniques to maintain a positive spirit throughout the rest of the week. 1. Intervention: QMHP welcomed client to the session. QMHP brainstormed strategies with client and encourage self-monitoring. QMHP provided mediation and relaxation techniques, as well as, simple praises and encouragement to continue the positive behaviors he was exhibiting. QMHP modeled pro-social behaviors for client to strengthen his understanding of them. QMHP engaged the client in a role reversal exercise and required the client to think about his goals. QMHP commended client on utilizing coping strategies to increase his understanding of feelings and emotions. QMHP provided positive feedback when client engaged in the more appropriate behavior. QMHP verbally identified the client's impulsiveness to the client and encouraged the client to use self-control strategies (i.e. decrease hyperactive behaviors. QMHP collaborated with mom regarding behaviors and performance in the home. QMHP provided support and encouragement to ensure client was comfortable and on track with achieving his goals and objectives. QMHP reviewed and gave feedback regarding ADHD and its causes and affect toward client’s well-being and emotional functioning. 2. Intervention: QMHP monitored client individualized behavior modifications in collaboration with his family. QMHP motivated client to respond to exercise and express his feelings. QMHP offered active listening skills. QMHP provided client with encouragement to demonstrate the positive behaviors and expectations they had been talking about. QMHP encouraged client to communicate to his mom when he feels down to prevent unwanted depression. QMHP praised client for staying on task. QMHP complimented client for utilizing acquired skills, paying attention, and focusing on the importance of the assignment. QMHP supported client displaying positive social interaction with peers and authority. QMHP praised client for listening and following directions and interacting safely during each intervention. QMHP observed client complying with rules and expectations. QMHP assisted client with recognizing his own personal strengths and how to apply them to reach his goals and objectives daily. QMHP explored the positive behavior options he was exhibiting with client to support his willingness to continue to make good decisions and have positive behaviors in at home, in school, and in the community. 1. Response: Client was responsive to counselor’s lesson. Client began to show greater control of his anger. Client appeared to decrease the intensity of his anger and frustration. Client was pleasant and cooperative and demonstrated a willingness to discuss the factors contributing to his undesirable mood. Client acknowledged that he tends to engage in disruptive behavior when he is frustrated with schoolwork or feels mistreated. Client accepted responsibility for his angry outbursts and aggressive behaviors. Client stated he will display anger control in the home. 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. Client has implemented the correct behaviors, by avoiding disruptive and impulsive actions demonstrated when client proceeded to walk away from negative behaviors. Client acknowledged QMHP's praise by saying thank you. Client was observed intervening and regulating his emotions correctly. Client was able to demonstrate fairness and kindness to peers and authority by treating them with respect and love. 2. Response: Client was able to process making good choices with QMHP. Client listed 2-3 behaviors that he was going to utilize in efforts to remain positive in the home. Client appeared to be receptive to receiving positive reinforcement from his mother, as demonstrated by him smiling and warm inviting body language. The frequency and intensity of the client's defiant affect decreased. Client continued to work on the psycho-educational activity. Client engaged in reflective thinking and expressed his feelings to QMHP. Client remembered to apply himself and utilize his strengths to focus on meeting the goals listed on his ISP. Client was acceptive of encouragement and decided to listen to his mother and do the right thing. Client was seen following desired rules and expectations without requiring redirection or additional breaks. Client had one on one with QMHP. Client realized his mother was trying to help him by pushing him to try on his own first and she would correct his mistakes. Client nodded in agreement and promised to do his work in order to stay motivated in the school setting and make something out of himself.