1/25/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed settling into class. client appeared to be in a standoffish mood as evidenced by his closed body language and looking away when greeted by QMHP. Client was encouraged to utilize relaxation techniques to uplift his spirit in order to have a fresh start to his day. Client was happy to be receiving the help that he needs and appreciates his teacher, staff, and his counselors for their support and praise. Client requires redirection 2-3x throughout the day, due to impulsive and hyperactive behaviors. Client cannot sit still for a long period of time, as seen constantly moving in his chair and making unnecessary noises during quiet time. Client has difficulty following directions and continues to give his teacher a hard time. Client attempted to run and jump in the hallway and had to restrained lightly to walk safely to therapeutic area. Client was put in 15 minute timeout and provided with coping / calming strategies to utilize during the break in order to return to the academic setting ready and prepared to work and learn. (PM) Client is observed having outbursts, as students prepared for lunch and pm studies. Client transitions into the lunchroom in a sad mood, as evidenced by him reframing from appropriate social behaviors by distancing himself from his friends and having an impolite attitude. Client displayed low interaction while sitting in his seat and facing forward. . Client was observed displaying inappropriate behaviors while transitioning from social environment back to class and was reprimanded by his teacher to leave his attitude at the door or he would be given additional consequences. Client went to his seat to and stayed to himself for the rest of the evening. (EOD) Client exhibits disrespectful manners when confronted and redirected. Client was seen going into session with an aggressive tone and walking in the opposite direction while stating, "I want to go home" "I don't want to be here". Client expressed sad and serious comments about hating school and not liking his teacher. Client was encouraged to think positive and to try to give it a chance. Client was encouraged of how lucky he is to be able to go to school and to be given so much love and support. Client was educated that life will get hard, but you have to believe in yourself and be thankful because it could be a lot worst. Client had one on one with QMHP to encourage him that he can manage his symptoms without relying on others for support. Client has shown improvement with reducing sadness, as evidenced by him smiling and laughing despite stressful environment. Client was able to get back on track and show more cooperative behaviors. Client needs improvement and has to be willing to make better choices in school in order to maintain appropriate behaviors. Client has shown minimum progress with following treatment plan. Client is required to practice and review objects/expectations at home with parent, due to him failing to meet his goals today. (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.