3/10/2023 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 stated he scratched his arm up bad because he fell off his bike. Client expresed he was in a lot of pain even with it wrapped up. Client was assisted with his bandages. It appeared client was cutting off his circulation from wrapping his arm too tight. 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 welcomed client to school and provided support and encouragement to ensure a good start to his day and to be on track with achieving his goals and objectives. QMHP inquired about weekend activities, asking what was exciting about your week. QMHP inquired about morning routine at home before coming to school. QMHP monitored client individualized behaviors in collaboration with his teacher and other mental health staff. QMHP encouraged client to make good choices and to utilize self calming techniques (i.e. counting to 10 and deep breathing skills) and processed with him about weekly behaviors, the good and bad, as well as, expectations. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. QMHP will teach client positive outlets and identify anger triggers. QMHP will assist client with developing effective focus techniques. QMHP will role play and demonstrate appropriate ways to interact with adults. (PM) QMHP provided praise when the client continued to display positive behaviors throughout the day, remaining on task and was very respectful to peers and authority. QMHP will teach positive alternatives to deal with anger. QMHP will provide opportunities for positive age communication. QMHP will verbally process with client ways to display improved impulse control. QMHP isolated client from distractions to decrease disruptive behaviors and to reduce excessive talking in class. QMHP explored the client’s capability to cope with his stressors. QMHP brainstormed how to resolve conflict without engaging in aggressive behaviors. QMHP offered help. QMHP encouraged client to continue having a good day. (EOD) QMHP monitored for acquisition of objectives. QMHP redirected client negative behaviors. QMHP encouraged client to stay in class and comply to rules and directives. QMHP encouraged client to be the example. QMHP encouraged client not to follow others that he see are doing wrong. QMHP intervened to assist in explaining behaviors to client. QMHP reflected with client on his day, both happy and frustrating experiences. QMHP encouraged client that tomorrow is a new day. QMHP processed client feelings. QMHP engaged in active listening. QMHP assisted client with recognizing his own personal strengths and how to apply them to reach his goals and objectives daily. QMHP reviewed several strategies for conflict resolution and positive social behaviors with client in efforts to increase client’s awareness. QMHP provided simple praises to client for his commitment to his progress. (AM) QMHP welcomed client to school and provided support and encouragement to ensure a good start to his day and to be on track with achieving his goals and objectives. QMHP inquired about weekend activities, asking what was exciting about your week. QMHP inquired about morning routine at home before coming to school. QMHP monitored client individualized behaviors in collaboration with his teacher and other mental health staff. QMHP encouraged client to make good choices and to utilize self calming techniques (i.e. counting to 10 and deep breathing skills) and processed with him about weekly behaviors, the good and bad, as well as, expectations. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. QMHP will teach client positive outlets and identify anger triggers. QMHP will assist client with developing effective focus techniques. QMHP will role play and demonstrate appropriate ways to interact with adults. (PM) QMHP provided praise when the client continued to display positive behaviors throughout the day, remaining on task and was very respectful to peers and authority. QMHP will teach positive alternatives to deal with anger. QMHP will provide opportunities for positive age communication. QMHP will verbally process with client ways to display improved impulse control. QMHP isolated client from distractions to decrease disruptive behaviors and to reduce excessive talking in class. QMHP explored the client’s capability to cope with his stressors. QMHP brainstormed how to resolve conflict without engaging in aggressive behaviors. QMHP offered help. QMHP encouraged client to continue having a good day. (EOD) QMHP monitored for acquisition of objectives. QMHP redirected client negative behaviors. QMHP encouraged client to stay in class and comply to rules and directives. QMHP encouraged client to be the example. QMHP encouraged client not to follow others that he see are doing wrong. QMHP intervened to assist in explaining behaviors to client. QMHP reflected with client on his day, both happy and frustrating experiences. QMHP encouraged client that tomorrow is a new day. QMHP processed client feelings. QMHP engaged in active listening. QMHP assisted client with recognizing his own personal strengths and how to apply them to reach his goals and objectives daily. QMHP reviewed several strategies for conflict resolution and positive social behaviors with client in efforts to increase client’s awareness. QMHP provided simple praises to client for his commitment to his progress. (AM) Client greeted QMHP by saying good morning. Client reflected on his weekend activities. Client said he woke up feeling good and was ready to have a good day. Client expressed positive thoughts about himself. Client stated he didn't need help with anything at the moment but would tell an adult if he needs help. Client communicated by nodding and exhibiting good eye contact. Client verbalized positive feelings about goals and objectives. Client communicated that he wants to work independently. Client displayed good participation in various settings and was responsive to all instructions, interacting well with his peers. Client responded in a positive manner acknowledging the positive reinforcement that the QMHP provided. (PM) Client said thank you and continued to do what he was told. Client said he was going to have a good day and decided to practice yoga poses with group member before returning to class. As the client has made more of his own decisions, he reported increased satisfaction and function. Client responded well to feedback, interacting well with his peers. Client agreed to behave and communicated a positive attitude when reviewing problem solving and self control strategies. Client promised he would try his best to correct himself when faced with conflict. Client was displaying respectful, non aggressive behaviors in lunch. Objectives were being met at this time, dispite stressful environment. Client demonstrates full understanding and capability of decreasing his symptoms associated with his mental illness and increasing his level of thinking, so that he can meet his objectives and make the right choices. Client appeared to be in a more calm mood, as evidenced by his upbeat spirit and enjoying himself during the activity. (EOD) Client avoided distractions in social setting, while utilizing anger management skills. Client seem to have a big influence on his peers. Client displays leadership skills by helping others and being a good citizen in school. Client acknowledged interventions and verbalized clear understanding. Client engaged in reflective thinking. Client communicated the do's and don'ts. Client was in a pleasant mood after feedback was given. Client was seen having a good evening. Client was able to identify the role he plays in each situation and continues to comply with authority rules and regulations. Client remembered to apply himself and utilize his strengths to focus on meeting his goals and objectives. Client administered positive behavioral expectations, reducing symptoms associated with his ADHD.