2/3/2023 EnchantaVaughn Approved 1. Behavior: When QMHP showed up to the home, client was just waking up from a nap. Client appeared to be in a jovial mood, as evidenced by his happy spirit and positive attitude. Client presented himself to be ready for his session, as evidenced by his upbeat spirit and enthusiasm when seeing QMHP. Client presented himself with a positive attitude and remained on task. Client was observed following directions and giving his undivided attention, even when his sister and brother were playing around him. Client participated in therapeutic exercise while displaying a cooperative manner. Client was seen displaying active listening skills, while following along with his assignment. Client displayed high confidence and cooperation while expressing his thoughts with his mom and counselor. Client was very creative and open minded and was supported for his excellent social skills, sharing and helping others in the home. Client communicates that he is striving to be a better version of himself every day and mom expresses that she is so proud of him for it. Client displayed great attitude in therapy setting and was praised for continuing to make progress with his daily life functioning. 2. Behavior: Client and his family were calm and engaging well with one another. Client and his mother were sitting next to each other making each other laugh. The family appeared to be on the same page in regard to client’s well-being and safety. Client appeared to be in good spirit and happy as evidenced by him smiling and engaging in conversation with counselor about his day. Mother was relaxed and happy to see client getting along with everyone since being a part. Client seemed to be handling himself well in the home and following the rules and adapting to the in-home schedule and routine without feeling or needing to stop the session, decreasing attention seeking behaviors in the home. Client expressed a positive attitude toward authority, as evidenced by him saying please and thank you. Client displays an increased pattern of independence through engaging in therapeutic activities. Client is making better choices now that he understands the role he plays and how his actions affect others. Client continues to acknowledge his mistakes and have made a huge contribution to work harder so that he can gain his father/grandmother’s trust back in hopes that one day he can have his family all together again. 1. Intervention: QMHP asked client about how he was doing today and conversed about his weekend activities. QMHP displayed gratitude while client shared his thoughts. QMHP reminded client of his goals and objectives to encourage consistency. QMHP employed positive reinforcement when client was observed drawing distance to himself. QMHP educated client about how well he has been doing since being in the pandemic. QMHP processed with client about increasing his interpersonal skills and communicating his feelings verbally with his mom and siblings. QMHP monitored client progress in demonstrating acquisitions of pro-social skills. QMHP reviewed client’s ISP objectives with him in efforts to reinforce his commitment to achieving them on a daily basis. QMHP facilitated worksheet to engage client in building rapport with mom in efforts to build trust and reduce verbal altercations between them. QMHP encouraged client to participate in desirable behaviors for the entire day. QMHP reinforced client’s positive behaviors by modeling more positive behaviors. QMHP encouraged client to maintain his behavior and stay committed to his objectives. QMHP offered simple praises to client for exhibiting the appropriate behaviors. 2. Intervention: QMHP supported client participation and recognizing his own behaviors around others. QMHP explored positive behavior options with client to support his willingness to make good decisions and have positive behaviors at home, in school, and in the community. QMHP commended client on his positive behaviors. QMHP explained and emphasized to client the importance of having a level grip on utilizing his coping skills to avoid mood swings and to promote positive thinking and self-motivation. QMHP monitored acquisition of behaviors and managing individualized behavioral modification programs. QMHP provided simple praises to client in efforts to motivate client to have a good rest of the day. QMHP encouraged mom to provide frequent positive reinforcement to maintain client’s interest and motivation in maintaining positive behaviors and completing his homework assignments. QMHP applauded the behavior of client and recognized how him and his mom had been interacting positively. QMHP reviewed the reported behaviors with client in efforts to allow him to express his point of view and self-reflect. QMHP did not have to prompt or intervene any negative behaviors during today’s visit. 1. Response: The client responded in a positive manner acknowledging the positive reinforcement that the QMHP provided by saying “thank you” while presenting a smile. Client attends therapeutic day treatment daily and has completed all psycho educational activities. Client utilized relaxation strategies appropriately. Client displayed self determination to stay focused and pay attention while mom and QMHP were talking. Client utilized meditation and relaxation techniques as needed. Client reported a decrease in symptoms following the relaxation techniques. Client verbalized positive feelings about building healthy relationships in the home. Client engaged in self-reflection and reflected on his day, the good and the bad. Client communicated his likes and dislikes. independently. Client displayed good participation in therapy session and was responsive to all instructions given by authority. Client understands that he is expected to act civilized and treat others with respect. Client responds well to praise, support, and positive reinforcement provided by QMHP and is seen increasing self-esteem and confidence. 2. Response: Client said he was going to practice coping strategies and relaxation techniques in all aspects of his daily living routine in hopes that he will be a better son, brother, and friend. Client was able to cooperate and comply to rules and regulations due to positive influence. Client implemented pro social skills successfully. Client has presented himself in a responsible way and is making progress in all areas. Client has become more involved in age appropriate social activities and was given positive reinforcement for these choices. Client demonstrated expectations and responded well to feedback. Client reported a decreased stress level due to his modulation of social contact, and the success of this was reviewed. Client was acceptive of extra help and support. Client utilized the resources provided and seem to be doing better with managing symptoms of ADHD. Mom enjoyed seeing client do the right thing. Client showed good understanding of what it means to be respectful, encouraging, mindful, and fair to others. As the client developed understanding of home expectations, he reported increased satisfaction and function.