3/2/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed unpacking his belongings and turning in his homework. Client started off his morning on a good note, as evidenced by his positive behaviors and displaying appropriate voice volume in class. Client was attentive to class announcements and followed instructions well without having to be told more than once. Client was well behaved in class during each activity and was supported for being on task. Client was observed preparing for testing by putting away his work and getting out a pencil and listening to instruction. Client did an excellent job keeping his eyes on his own paper and concentrating during testing. Client seemed to be in a good mood and satisfied with his answers. Client showed high self-determination by reviewing and checking over his answers. Client communicated positive non verbal cues that he was proud of himself and excited to receive a good grade. As the client prepared for lunch, he is witnessed exhibiting appropriate manners and being polite to others. (PM) Client transitions successfully to the lunch room to eat and attend psycho educational. Client picked up his food nicely and respectfully without pushing others or cutting the line. Client asked for permission to go see his counselor. Client sat with counselor and had one on one. As the client, engaged in self-reflection and debriefed about his day he mentioned that he went home and observed and took mental pictures so that he can express it in his drawing. Client was excited to finish drawing activity and earn a reward. Client displayed good emotions toward mental health professional for the positive feedback and continues to express positive thoughts about himself and others. Client works well by himself and is supported and assisted with developing positive relationships with his peers. Client displayed cooperation and showed effort to building new relationships by contributing to group discussion. Client was able to transition back to class in a positive manner and join specials. (EOD) Client was seen interacting well with others during group activity. Client displayed excellent sportsmanship and ability to work as a team. Teacher had no complaints from the way client behaved today and reported him to be on task and following directions. Client was encouraged to keep up the good work and demonstrate this same conduct after school, at home, and in the community. Client nodded in agreement. Client utilized his free time to write in his journal and study. Client was careful not to interrupt others who were still working, ending the day meeting all objectives due to managing his anger and complying to school rules and regulations. (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.