1/27/2023 EnchantaVaughn Approved (AM) Upon arrival, client was seen entering the school building laughing and playing with his peers. Client greeted counselor and staff and went straight to class. Client was observed giving teacher a hard time. Client displayed frustration and attempted to walk out of class. Client presented defiance toward authority when confronted about his poor attitude. Client was sent to reflect and cool off. Client appeared guarded and offensive due to encountering other challenges in academic setting. Client was reported to have struggled to maintain expectations and could utilize a break. Client displayed attention seeking behaviors trying to pressure other peers into wrong doing. Client was prompted to focus on himself and stop being a trouble starter. Client required to be monitored and assisted with getting back on task. (PM) Client displayed civilized manners in lunch by sitting quietly with his class and being polite to staff. Client seemed to be stable and content, at this time. Client did not make it out of lunch on a good note and had to be restrained and carried to QMHP for assistance. Client is witnessed yelling, shaking his arms and legs aggressively, complaining, flustered, upset, and being defiant while given redirection. Client ignored prompts and would not listen when directed to get up and sit in his chair. Parents were contacted immediately. Mom stated client was disrespectful to her at home this morning and would process with him at home to figure out what’s going on. Client was able to deescalate unwanted behaviors and communicate appropriately. Client promised to be good and listen to authority requests and demands. Client channeled his energy to his assigned work. Client utilized relaxation techniques by deep breathing and putting his head down. Client demonstrated self-calming strategies and went back to class smoothly and safely. (EOD) Client communicated he does not like school and is not interested in doing any work. Client struggled staying on task and needed additional direction. Client had to be reminded of rules and expectations. Client was observed in a upset mood, as evidenced by his poor performance in class and negative comments. Client demonstrated impulsive, defiant behaviors that were reprimanded by teacher and counselor. Client prepared for dismissal, no incident occurred at this time. Client was not rewarded today, due to not meeting objectives. (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.