1/24/2023 EnchantaVaughn Approved (AM) Upon arrival, client entered the classroom in a hostile and disruptive manner. Client did not start his work right away. Teacher suggested client go see his counselor for not being productive or polite. Client was confronted and sent to have one on one with his counselor. Client stated he didn't get much sleep the night before and was not in a good mood. Client was encouraged to lose the attitude and get his work done before he's penalized for his actions. Client promised to be more respectful and comply to classroom rules. Client failed to complete his assigned task as he was observed talking to his peers. Client was off task as he discussed non- related school topics with his peers. Client took toys and snacks out his bag, as he appeared to be showing it off to his peers at his desk. Client lacked respect for authority figure. Client struggled to refrain from using verbal aggression during morning hours as his peers appeared to be using profanity towards him. Client appeared to be irritable as he was seen pacing the floor. Once client appeared to be calm, he began explaining how he felt disrespected due to his peer cursing at him. Client appeared to be calm after interventions. (PM) Client displayed disruptive behaviors in class. Client was sent to speak with his counselor. Teacher praised client for all of his efforts in the past but was very disappointed at him today. Teacher did not understand what went wrong and why client was acting this way. Client verbalized he did not want to be in the class but instead of asking for a break he took his attitude out on others. Client displayed negative body cues (rolling his eyes, shrugging his shoulders, and shaking his head). Client was in a nonchalant mood. Client was inquired about his feelings. Client was reminded that it isn’t fair to mistreat others because he’s not enjoying himself. Client was educated that it hinders the whole class when the teacher cannot teach. Client looked down and displayed sadness. Client communicated that even if he was in another setting he would react the same. Client had trouble interacting with peers, due to being upset. Client finally broke his silence and opened up to QMHP. Client was able to play games and engage with his peers in a positive manner after conversing with his counselor. Client was ready to go back to class and make better choices. (EOD) During the final period client appeared to have a transition in his demeanor as he was able to complete his assigned task. Client appeared to be energized after his break as he socialized with his psycho educational group as well. Teacher did not report any negative behaviors at this time and client was able to turn his day around completely. Client was observed packing up and waiting to be dismissed, as the school day came to an end. Client needs improvement with all objectives, as seen throughout the day. (AM) QMHP will teach client necessary coping skills to decrease impulses. QMHP will brainstorm strategies with client and encourage self-monitoring. QMHP will provide mediation and relaxation techniques. QMHP inquired about after school activities. QMHP will collaborate with teacher regarding behaviors and performance. QMHP applauded client for being the bigger person. QMHP modeled language for client to use while in school, home and in the community that will promote pro-social behaviors and effective communication. QMHP reiterated to client the benefits of following the rules and of the privileges he can receive when he does so. QMHP assisted client with identifying privileges that he would like but does not receive due to his negative behaviors; in efforts to stimulate his thinking about cause and effect of his behavior choices. (PM) QMHP provided simple non-verbal praises as client was observed displaying positive classroom behaviors. QMHP trained client in taking steps to prevent problems including displaying positive classroom behaviors. QMHP refocused client as he was observed becoming fidgety and restless. QMHP will review and give feedback regarding ADHD and its causes and affect toward client well-being and academic functioning. QMHP will provide client with support and encouragement. QMHP will monitor, observe, and redirect client behaviors as needed. QMHP will build rapport. QMHP will explore positive self-talk, use instruction modeling, and increase social communication skills with positive reinforcement role play activities. (EOD) QMHP used positive regard as he told the client that he appeared to have positive classroom management in class earlier in the day. QMHP informed client of more acceptable and expected responses to classroom and hallway situations that would normally lead client to be triggered and display inappropriate, negative behaviors while in the classroom or hallway. QMHP will educate client on behavior modification to help client identify what behavior he needs to decrease and avoid daily. QMHP will utilize behavior modification system to aid the client with following directions given by authority figures. QMHP will meet with client daily to discuss progress and expectations that are working and not working in school daily. (AM) Client utilized coping skills and impulses started decreasing. Client was observed strategizing a plan to better himself by writing down his thoughts and feelings and exploring his creative side with arts and crafts. Client was taught to deep breathe until he is ready to process his feelings. Client was reported displaying age appropriate behaviors and was productive and studious throughout the day. Client thanked QMHP for the support and assistance and helping him stay on track with his goals and objectives. Client was able to be redirected successfully. Client stated he would try better self-management as the day pursues. Client was able to contain impulsive actions. Client was observed having positive interactions with peers and mental health professionals. (PM) Client demonstrated responsibility and leadership. Client was acceptive of redirection. Client was able to complete his classwork with less than 3 prompts to redirect his focus to the classwork. Client showed an improvement from previous days experiences in the classroom with client. 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. (EOD) 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 expressed that he should receive an incentive for his display of desirable behaviors throughout the day. 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 with peers by walking away and telling an adult first. Client demonstrated more acceptable responses, avoiding anger provoking situations in the classrooms and hallways.