1/13/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed entering school in a good manner and displaying a positive attitude. Client demonstrates good sportsmanship in the breakfast line by waiting his turn and being polite to staff. Client was observed starting his day off on a good note and waiting for teacher instructions. Client initiated small conversation with peers until it was time to start his work. Client implemented responsible behavior and was given a thumbs up by mental health professional that he was on track with goals and objectives. Client was acceptive of the non-verbal cues and smiled back and continued displaying appropriate interaction in all settings. Teacher reported client walked into class in a pleasant and joyful mood. Client is very active in class and engaging with his peers. Teacher communicated client can take his break after all of his assignments are complete. Client was seen interacting well with peers at his table. Client exhibited excellent social skills inside and outside of class. Client demonstrates good teamwork by sharing and taking turns. Client is cooperative and attentive during lesson. Client was engaged and active and doing a good job with managing his symptoms. Client was able to maintain age appropriate behaviors without initiating or contributing to conflict. Client had a hard time transitioning, due to playful environment but quickly changed those behaviors when he saw his counselor and teacher getting ready to pull him to the side. (PM) Client entered lunch in a safe and positive manner. Client joined his peers in the lunch line and engaged in appropriate conversation without being loud or all over the place. Client is observed going to his seat, eating correcting, and throwing his trash away. Client transitioned to session to begin psycho educational. Client is monitored being a good helper and participating in group activity. Client displayed good sportsmanship and was observed being very social and interactive with peers. Client participated in psycho educational activity without giving QMHP a hard time. Client was inquired to share something that he has learned today. Client stated “having an optimism mindset and seeing the positives in all things no matter what it is”. Client was asked about his personal motivators. Client communicated treats and being able to color. As the client engaged in reflective thinking with mental health professional, he was encouraged to reflect on his day, good and bad. Client displayed active listening skills while others shared their stories and was respectful and polite to his group. (EOD) Client went back to class to finish his work. Client is seen participating and working as a team. Client demonstrates appropriate social behaviors at his table and careful to give his classmates their personal space. Client is observed keeping his hands to himself and being the example for his peers who were having a hard time staying on task. Client appeared to be in studious mood, as evidenced by his focus and concentration in class. Client displayed a positive attitude while waiting for teacher to start the next activity. Client was acknowledged for his patience and waiting for permission before getting out of his seat. Client was observed helping others when he finished his part of the assignment. Client has been able to control his temper and impulsivity while eliminating disruptive behaviors. Client appeared to be enjoying himself around others and listening to teacher instructions. Client was attentive and well behaved. Client was observed doing the right thing and did not have to be given additional prompts, thus achieving all goals and objectives listed on ISP. (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.