3/1/2023 EnchantaVaughn Approved (AM) Upon arrival, client was seen coming to school in a low tempered mood and appeared a little tired. Client was approached by his counselor before walking into class. Client displayed normal affect at this time. Client spoke with QMHP about his needs and the way he felt. Client was thankful for the support and care. Client joined his class in the morning activity. Client was observed in his seat and listening to instruction. Client earned points for being respectful to his teacher and polite to his peers. Client prepared for lunch in a civil manner without pushing or shoving and transitioning safely to the cafeteria. (PM) Client was witnessed in lunch displaying good social skills and using appropriate voice volume. Client was compliant to rules and handled himself well around his peers. Client had difficulty going into his selected elective. Client complains about going into quite a few classes since the new changes have taken place. Client is having difficulty staying on task and needs support and one on one in order to regroup and take his school day seriously. Client presents a negative attitude when confronted about his choices and acting out. Client displays negative episode and talking back to authority. Client has struggled with transitioning between classes, due to wanting to be somewhere else (i.e. on break, playing games, or roaming the halls). Client dislikes the fact he doesn’t get to see his favorite teachers as often and have communicated that this is effecting him and makes him upset. Client have verbalized that he does not like some of his teachers and wished things went back to the way they were at the beginning of the school year. (EOD) Client was able to reduce disruptive behaviors and return to class in a more productive and positive mood. Client was observed participating in group activity. Client displayed cooperative and compliant behaviors, staying on task and following teacher’s instructions. Client displays appropriate classroom etiquette, as evidenced by paying attention to teacher and interacting well with peers. Client was observed listening and being attentive to his work, dismissing from class with a better attitude. Unfortuanatly, client did not meet objectives due to inappropriate conduct during the evening academic hours. (AM) QMHP had one on one with client. QMHP explored positive behavior options he was exhibiting with client to support his willingness to continue to make good decisions and display appropriate behaviors in school. QMHP processed thoughts and feelings. QMHP inquired about morning routine and previous activities. QMHP encouraged client to utilize positive self talk as a means of decreasing anxiety and managing frustration when encountering difficult or challenging circumstances. QMHP talked to client about his confidence levels and how they can affect his day and self esteem. QMHP encouraged client to make good choices. QMHP monitored acquisition of behaviors and managing individualized behavioral modification programs. QMHP provided simple praises to client in efforts to motivate client to have a good rest of the day. (PM) QMHP supported client with building new relationships in lunch and interacting with his age group. QMHP assisted client with breathing and relaxation exercises in efforts to reduce symptoms of ADHD. QMHP utilized behavior modification strategies including removing client from the stimulant and stressful environments in efforts for him to reduce impulsive and defiant behaviors. QMHP assisted client in exploring other coping strategies that he had previously used to solve problems and avoid conflict. QMHP observed client in academic and social settings throughout the day to determine the need for redirection. (EOD) QMHP reminded client of goals and objectives and what things he can improve in order to successfully meet ISP. QMHP held consultations with client and teacher about effective intervention strategies that build on the client’s strengths and compensate for his negative behaviors. QMHP encouraged teachers to provide frequent positive reinforcement to maintain client’s interest and motivation in maintaining positive classroom behaviors and completing his school assignments. QMHP reviewed the reported behaviors with client in efforts to allow him to express his point of view and self reflect. QMHP did not have to prompt or intervene any negative behaviors during dismissal, as he demonstrated adherence to classroom rules and expectations. (AM) Client greeted mental health professional by waving and smiling. Client said good morning upon arrival and grabbed breakfast to prepare for his day. Client demonstrated excellent social skills due to positive interaction with peers and helping others. Client expressed he was feeling good. Client stated he wakes up on time for school but has a hard time going to bed on time due to playing video games and watching tv. Client admitted that losing out on sleep is not good for his health or education. Client communicated good “I statements”, such as, “I will be a leader” “I will show respect” “I will do my work and listen to my teacher”. Client expressed low confidence when talking about things he dislikes and other challenging tasks. Client explained he likes to be rewarded and praised by others. Client promised to do the right thing. Client was observed following directions and participating in class. Client said thank you and returned to his seat. (PM) Client seems to enjoy making new friends in school. Client interacts well with his peers unless he feels bullied. Client often follow behind others who are being disruptive and has to be reminded to get back on task. Client utilized breathing and relaxation techniques during therapy session and free time in class. Client was able to reduce hyperactive behaviors with additional support and redirection. Client is seen dealing with stressors and coping appropriately. Client utilized conflict resolution skills in school by problem solving on his own and compromising with his peers. (EOD) Client reviewed goals and objectives. Client admitted he needs improvement and plans to practice skills and strategies at home in order to stop complaining about doing work in school. Client was able to eliminate unwanted behaviors and implement new strengths. Client benefited from positive reinforcement. Client engaged in self-reflection and role-playing activities to correct his mistakes. Client demonstrates excellent conduct at this time while displaying responsible behavior, ending the day on a good note.