1/12/2023 EnchantaVaughn Approved (AM) Upon arrival, client was witnessed walking to school with mom and sister. Client is observed displaying appropriate behaviors and expressing positive communication skills. Client greeted staff and QMHP by saying hello and good morning. Client grabbed breakfast and was respectful during the announcements, as reported by hallway staff. Client was seen going straight to his seat to prepare for morning work. Client put away his belongings and waited for instructions without any interruptions or horseplay. Client was seen displaying age appropriate behaviors and cooperating with his peers during group stations. Client was on track with goals and objectives. Teacher reported client has been on task and making good choices. Client was praised for his efforts and hard work. Client was observed listening and following directions and being respectful to authority. Client expressed positive thoughts about school and exhibited a good attitude toward mental health professional. Client was able to transition to the lunch setting smoothly and quietly, walking in line and waiting patiently for his class to grab their meals. Client displayed great social behaviors, interacting well with others and being polite. Client asked for permission to sit with his counselor and promised to return to class afterwards. (PM) Client was interactive and supportive in group setting. Client showed excellent attitude and participation. Client reported feeling less frustrated at this time. Client was able to verbalize positive feelings and contribute to discussion. Client asked and answered appropriate questions. Client gave full effort to completing his work. Client was supported for displaying appropriate interaction and listening to all authority. Client joined his group and exhibited positive energy. Client appeared to be in a good space. Client displayed appropriate gestures and behaviors. Client waved and smiled while going into session, and support was provided at this time. Client exhibited good listening skills and ability to cope with stress and anxiety. Client displayed a pleasant attitude. Client expressed positive comments in class. Client was seen listening and following directions. Client was calm and quiet in his seat. Client displayed productiveness and patience when completing his assignment. Client was attentive and exhibited interest in all subjects. Client received positive feedback for his implementation of coping techniques. Client was directed to read during free time and utilize deep breathing skill and take small breaks when needed. Client was acceptive then returned to his duties and responsibilities. (EOD) The client was able to stay in class while displaying a positive attitude. Client required little to no redirection at this time, as evidenced by him doing what he is asked and adhering to school rules. Client understands that it is important to “stop, think, and act differently” if we want to be successful in school. Client verbalizes good thoughts about himself and others. The client reported that he has been successful in reducing levels of tension and increasing levels of relaxation. Client shared his feelings and thoughts with QMHP. Client responded well to the positive reinforcers provided by QMHP. Client followed his instructions and stayed on task until dismissal. Client was able to achieve goals and objectives, as observed and reported. (AM) QMHP welcomed client to school. QMHP inquired about evening and morning. QMHP asked how client was feeling. QMHP asked if client needed help with anything. QMHP encouraged client to have a good day. QMHP monitored individualized behaviors for acquisition of objectives. QMHP encouraged client to listen to his teacher. QMHP encouraged client to be the example for others. QMHP encouraged client not to follow others he sees that are doing wrong. QMHP reminded client of goals and objectives. QMHP intervened to assist in explaining behaviors to client and what he needs to work on if he wants to meet his goals and objectives. (PM) QMHP will provide strategies for coping and self-control when faced with conflict. QMHP will review and give feedback regarding ADHD and its causes and effect to well-being and school performance. QMHP will teach client meditation skills to decrease anger and frustration. QMHP assisted client in developing more social skills. QMHP inquired about possible challenges client can experience with applying this skill. QMHP provided feedback. QMHP reflected on client goals and objectives. QMHP isolated client from distractions to decrease disruptive behaviors and to reduce episodes. QMHP assisted client in normalizing the changes that are occurring in school and session. QMHP will implement a routine that will encourage client to be responsible and promote self confidence in academic and social settings. (EOD) QMHP reflected with client on his day, reviewing both good and bad experiences. QMHP processed with client, "what would you do different tomorrow”. QMHP encouraged client to have a good evening. QMHP encouraged client that tomorrow is a new day. QMHP praised client for utilizing acquired skills and being able to get back on track without episode. QMHP supported client with displaying positive social interactions with peers and authority. QMHP reinforced appropriate coping skills in dismissal setting. QMHP processed client positive responses and challenged client to maintain appropriate behaviors throughout the entire week. (AM) Client had one on one with QMHP. Client verbalized positive feelings about evening and morning. Client said he was feeling good and plans to have a good day. Client shook his head and returned to his work. Client displayed management of individualized behaviors. The client has not overreacted with anger to minor frustrations or irritants. Client responded in a pleasant manner acknowledging the positive reinforcement that the QMHP provided. Client is making progress with expressing his feelings and showing others respect and courtesy by talking with appropriate tone, initiating conversation with peers, and waiting for his turn to talk before blurting out loud. Client said he loves coloring activities and utilizes this to relax and stay focused in class. Client was honest about his wrong doing and is working to change these behaviors. (PM) Client was able to reevaluate himself and display a more positive attitude toward peers and authority. Client has become more involved in age appropriate social activities while being supportive of others. Client did not display any outbursts during the role play exercise. Client learned to look for similarities rather than differences in others. Client demonstrated expectations and responded well to redirection from teacher and TDT staff. Client did not run away from group or get frustrated like he normally does during room changes. Client reported a decreased stress level due to his modulation of social contact, and the success of this was reviewed. (EOD) As the client developed understanding of academic expectations, he reported increased satisfaction and function. Client responded well to feedback, interacting well with others. Client was able to speak calmly and demonstrate his improved communication skills while engaging in self-reflection. Client implemented his plan for restoring relationships, and this was reviewed. Client engaged in self-reflection, discussing good and bad parts of his day. Client said, "thank you". Client chose to get back on task, as observed by him listening and following directions. Client appeared to be learning from his mistakes and correcting them throughout the day. Client dismissed without incident