revised BIRP notes

Please revise notes to third person and structure notes similar to attachement file. NOTES SHOULD BE STRUCTED LIKE ATTACHMENT FILE. There are 3 different clients. Please add name of each client note above their sections

4 sections under each client. Behavior:
Intervention:
Response:
Plan:

Jurnee Moe

Behavior: Met with client Via Telehealth in home. During assessment, client exhibited symptoms of depression and explained that
she has experienced emotional abuse from her father. “All of this is happening to me out of nowhere. I’lI be okay one day, and
sad and crying out of no where another. I get agitated with my family and brush them off when they try to help me. My father
yells at me and threatens to throw my things out. Later, he will say to me ‘you don’t love me’. I don’t talk to him as much
now, but I talked to him 4 days ago and he yelled at me.” Today she was very calm and explained that screams trigger
her depression. “Yelling breaks me down. When I cry, my hands and legs shake.” She was flat when expressing that does not
wish to mend a relationship with her father. Client reported that she had thoughts of suicide years ago but does have those
thoughts presently. “I told my group chat I wanted to kill myself and they said I just wanted attention. I turned my phone off and they sent me so many messages.”

Intervention:
Using CBT techniques, talk therapy was used to validate, and support Journee’s experiences with depression by encouraging
her to express and process her feelings of sadness. I challenged Journees negative thinking when she said “I feel like
an outcast. The other kids have group chats without me and when I tried to help them with their work, they said that I think
that I’m all that.” by identifying and adjusting her thoughts to be more accurate, I assured her by saying, “You are not an
outcast, you’re a leader. When you’re in grade school it feels like you have to ‘fit in’ but instead of being a group thinker, you
are an independent thinker, traits like that tend to give you an advantage in life when applied correctly. I recommended that
the client list three positive words she would use to describe herself “funny, caring, shy”, then list three strengths “painting,
drawing, writing poems” I feel that this could be used as a coping skill for Journee when se begins to feel depressed.

Response:
When inquiring about stressors, Journee responded by detailing that a lot of her depression is linked to her past trauma with
her father. “He yelled at me and embarrassed me at the mall in front of everyone. When people yell at me, I just shut down
now. I was scared of him when I was younger, but not now. Right now, I have no emotions towards him, and we don’t really
talk. My mom told me that before I was born, she pulled out a knife on him and when the fblice made it there, he cut himself
and lied on my mom and told the officers that she cut him” Journee was very engaged during our conversation and was open
to meeting regularly. She is now home-schooled but wants to be around more people her age. Journee also may be
experiencing some struggles with her self-image “My teacher body shamed me for wearing short shorts, my shorts were the
same length as another girls, but I was told that my shorts were too small.” She revealed that when she was sad, she
intentionally made herself throw up when her mother forced her to et her food. When inquiring about this, she assured that
this was a one-time occurrence. At the end of the session, she agreed to wanting to attend more sessions to assist with these
emodons

Plan:
Next appointment scheduled April ‘1 4th. Will continue to address client’s symptoms of depression, develop better coping skill
for depression, increase self-confidence and monitor any potential suicidal ideations.
Strengths:

Kai Liles

Benavior:
A flat behavior was displayed when observing Kai during her session. The details Kai provided about her day-to-day chores,
schoolwork. emotions. and interests were extremely detailed. “My grades are great! I’m disappointed today because I have to clean my room. Every day I have to clean the dog’s room after I do my homework.” Speaking of her prior experiences with therapy, she said she had previously had a therapist who stopped showing up. “My mom was really mad with my other therapist because he said that his friend had covid and he had to take care of him and couldn’t return to work. I think that it was okay that he had had to take care of his friend but she was mad.” Kai also described her perception of therapy. “Therapy is like people asking questions about your life. You have to tell them the correct thing.” Kai was able sit still the entire interview but stopped speaking periodically when her mother came near. Kai was removed from class to participate in the session, while her mother stood outside of the car for privacy. When her mother would sit inside to warm up. Kai’s responses
were more flat than when she was alone

Intervention:
When Kai was asked to describe her typical school day and the tasks she would perform during that day, CBT Talk Therapy was used as an aid to assist her with attention deficit disorder. As opposed to asking her a series of in-depth questions, I broke down the questions into smaller parts so that she could better explain what her days are like by describing each part of the day. Additionally, I requested her to describe what causes her to become distracted and what she does to avoid it. “I know
when I aet distracted because | get bored. Ijust start looking around around my legs shake.

Response:
Kai was very responsive, and she was able to effectively explain. her frustrations as well as describe a schedule that had been made in order to keep her organized in the future. As a result of sharing her perspective, she was able to describe how easily she becomes frustrated and distracted, and how these are qualities she would like to improve in the future. “When I finish my work it’s hard to sit still.” Kai told me when I asked her what her distractions are when she finishes her work.

Plan:
During the sessions that are to be held in the future, I intend to assist my client in becoming more organized, focusing on schoolwork, paying attention and listening to others, becoming better acquainted with others, and having fewer behavioral issues. Additionally, I want to help Kai improve her ability to cope with feeling agitated by helping her develop better coping

Michelle Corona

Behavior: When I assessed Michelle, I noticed that she appeared a bit anxious at times. Although this was supposed to be an individual session, there were people around her who were watching. It was evident that she was hesitant to tell me anything wen answerng a few questions. During the course of our conversation. Michelle shared her interest in makeup YouTube videos and parenthood. During the session, she detailed her aspirations to become an ultrasound technician in the future. In our discussion of anxiety, Michelle described in detail what the sensation of anxiety was like for her and how it impacted her life.
Whenever she has to take tests. she will sweat a lot. her breathing is unstead. and she is unable to focus on the task at hand.

Intervention:

It was determined that Michelle would experience anxiety as a result of the role-play and scenano that was created with Cognitive Behavioral Therapy. After I inauired into what she does in order to reduce her anxiety, she replied. “I take deep
breaths as one of the things that she goes.

Response:
As Michelle explained in such a clear and concise manner, past experiences with bullying may have been a contributing factor to her current anxiety symptoms. In the process of relocating schools, Michelle felt the need to regroup in a hurry. “I was getting bullied badly.” Michelle talked about how she was being mistreated by her peers at and her previous high school, and how they would mistreat her for no apparent reason. As a result of switching schools, she states that she is happier and has more supportive friends now as a result. The majority of her responses to my questions were short and brief, and most of the answers to my questions were either yes or no in nature. As I sensed that she would not be comfortable with self-revealing, I changed the subject and asked her about her child since could sense that she was a bit uncomfortable. She explained that the baby was sick last week, which caused a delay in therapy.

Plan: In order to helo her manage her emotions and reduce mood swings, I plan to implement positive coping skills and communication skills to help manage her emotions. It is my goal to assist Michelle in improving the way she interacts with ochers ane mange ver anxiety .

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