12/27/2023 EnchantaVaughn Approved (AM) Upon arrival tje Winter Program, client was observed entering class in a uptight mood, as evidenced by him cringing up his face and frowning. Client presented a negative attitude toward his counselor due to being upset that he had to deal with the consequences of his actions. Client was standoffish and distant, ignoring debriefing and refusing to communicate his feelings when inquired about his break and time off from school. Client avoided all contact and returned to his group room setting to begin his morning assignment. Client was observed at his desk following directions and being courteous. Client is seen walking quietly in the hallway and preparing for lunch. Client displayed good social behaviors, as evidenced by increased peer interaction and helping others clean up their trash. Client shows he is capable of being a responsible student and was supported for his contribution and cooperation in and out of class. (PM) Client was observed in his seat and being a good listener while teacher reviewed today’s lesson. Client exhibits a nonchalant attitude but participated in all assigned activities. Teacher reported client was having a good day and is making progress with his work. Client demonstrates excellent team building skills by being a leader and providing positive encouragement to his peers. Client displays age appropriate skills throughout the day avoiding conflict, staying on task and focusing on achieving his goals. The client was supported as he focused on the part of himself that wants to get better. As the client was provided with a calm environment and reassurance that he would be cared for, his level of agitation has decreased. Client continues to avoid mental health counselor prompts and directives and is encouraged to be respectful and polite. Client expressed little interest in coming to his session and attempted to make inappropriate noises to interrupt others who were trying to learn. The client continues to be very cautious about expressing his emotions and was encouraged to do this at his own pace. The client has to be reminded to communicate positive feedback and not to let his ego get in his way of learning and receiving help. Client was not acceptive of redirection and responded aggressively by saying “I don’t want to talk to you”. Client was sent to male counselor to engage in one on one therapy to discuss his concerns. (EOD) Client was monitored in individual setting listening and displaying low level of participation. The client was taught alternative ways of expressing negative emotions (e.g. writing, drawing, physical activity, or talking to a friend) but the client’s psychotic thinking persists, despite the use of coping skills and other interventions, and he was provided with additional support in this area. The client do not like to admit what he does wrong and constantly gives authority figures a hard time. Client have not utilized healthy coping practices and was urged to do so. The client has a difficult time transitioning from setting to setting due to his relationship with different staff members. Client is unable to identify many significant positive hopeful things in his life and is provided with examples of those. As the client prepared for dismissal, he was observed sharing and being fair to others. Client remained in class and was able to refocus his attention to more favorable acts of kindness, achieving objective 2 but failing to achieve objectives 1 and 3, as evidenced.