3/16/2023 EnchantaVaughn Approved (AM) Upon arrival, client was seen getting to school in a civil and timely manner. Client saw QMHP and ran to give her a hug on the way to class. Client stated he ate breakfast at home and had snacks for lunch. Client communicated that his mom rewards them for completing all of their chores and getting good reports at school, as indicated by yesterdays report. After one on one client walked to his homeroom class in a quiet and safe manner. Client appeared to be in a fantastic mood as evidenced by his positive energy and joyful spirit. Client was thankful of the daily report from his counselor and proceeded to start his day off on a good note. As the client was provided with a calm environment and reassurance that he would be cared for, his level of agitation has decreased. Client was observed interacting well with his peers and asking for permission to join morning group. Client displayed a positive attitude when returning back to class and was able to go straight to his seat in preparation for morning announcements. Client displayed non aggressive behaviors and was seen following all directions and listening to his teachers, indicating that he was already having a good start to his day. (PM) Client was observed sitting quietly at his desk reviewing his class assignment along with his teacher. Client seemed to be in a positive mood, as evidenced by his happy expressions and excitement to come to group session. Client demonstrated ability to multi task by working independently and helping his peers with staying on task. Client displayed a good attitude and was very respectful in class. Client was seen being polite and respectful. Client exhibited high participation in all of his assigned activities and completed his work promptly. Client was observed making insightful comments and engaging in group discussion. Client demonstrated excellent mannerisms in various settings, transitioning to specials with a positive attitude. (EOD) Client was praised for all of his hard work and for correcting all unpleasant behaviors. Client continues to build new interpersonal relationships with his peers, sharing and taking turns in a civilized manner. The client was provided with positive feedback regarding his socially appropriate use of eye contact and positive body language during social interactions. Client expressed positive attitude toward mental health professional, exhibiting that he is capable of managing his emotions while utilizing effective coping skills (e.g. taking small breaks when he becomes frustrated and try to talk out his feelings before engaging in hurtful actions). Client communicates positive feelings toward his group members and teachers, as observed. Client continues to execute responsibility for his actions by making good choices and utilizing all strategies. Client was cooperative during dismissal and announcements. Client was able to achieve all objectives during school today. (AM) QMHP employed positive reinforcement when the client was able to achieve all of his objectives, and encouraged him to maintain his positive behavior by providing him with a review of his objectives. QMHP educated the client with relaxation strategies such as deep breathing and counting to 10 to decrease the client’s aggressive behavior. The client was encouraged to use good judgement, and respect authority figures. QMHP provided client with a release of energy by walking to get a drink of water to help him relax and decrease his hyperactive behavior. QMHP used appropriate behavior modeling by pointing out a peer that is demonstrating positive behavior to decrease the client’s impulsive behavior and encourage him to use self-control. QMHP monitored progress in demonstrating individualized pro-social skills (e.g. anger management, education, problem-solving, conflict resolution, appropriate verbalization of feelings, and cognitive-behavioral programming). (PM) QMHP provided individual, group, and family counseling based on specific treatment objectives. QMHP reminded client of goals and objectives. QMHP collaborated with teacher and administrative staff in regards to school rules and regulations, classroom management, effective teaching practices, following verbal and non-verbal instruction, role playing exercises, and an appropriate incentive system. QMHP educated client about using good manners in school and offering alternative methods and suggestions to model appropriate language that client should use to ask for things or to get someone’s attention. QMHP processed client feelings and offered choices of what to do when faced with conflict or challenged in the school setting. (EOD) QMHP facilitated a group discussion to talk about common mistakes children with ADHD make and how he can make better choices. QMHP reviewed school expectations and how client should conduct himself around peers and authority. QMHP praised and recognized client for his hard work, efforts, participation, and working towards improvement by changing daily habits and implementing a positive and consistent routine. QMHP supported client with meeting his objectives and coping with stressors without needing additional redirection or prompts. QMHP encouraged client to continue displaying age appropriate behavior, and the benefits of this will be reviewed with parent and teacher. QMHP conducted a review of previous week regarding mindful seeing and mindful listening. QMHP assisted client with problem-solving. QMHP provided client with feedback. QMHP provided client with positive reinforcement. QMHP encouraged client to practice relaxation and coping techniques in social/academic environment, at home, and in the community. (AM) The client responded in a positive manner acknowledging the positive reinforcement that the QMHP provided by saying “thank you” while presenting a smile. Client utilized relaxation strategies The client showed his gratitude for being able to release physical tension stating that he feels relaxed and able to catch his breathe again. The client stated that he can be good also, and told QMHP that he will do his best to follow directions and keep his hands to himself. Client was able to cooperate and comply to rules and regulations due to positive peer influence. Client implemented pro social skills successfully. (PM) Client attends therapeutic day treatment daily and has completed all psycho educational activities. Client has presented himself in a responsible way and is making progress towards goals and objectives. Client maintains classroom etiquette by sitting in his seat during instructed classwork, raising his hand and asking appropriate questions, being respectful at his table/desk, remaining quiet during quiet time and active during activity time, listening to his teacher, modeling appropriate behavior, and earning points for a reward without begging for a treat. Client says please, thank you, and excuse me. Client shows empathy towards others and is caring to his peers, as evidenced by him hugging, playing, smiling, and complimenting others. Client avoids negative language (i.e. cussing and using aggressive words). Client engaged in self reflection and reflected on his day, the good and the bad. Client communicated his likes and dislikes. (EOD) Client recognized his triggers and was able to identify common interests and similarities him and other ADHD recipients share. Client understands that he is expected to act civilized and use his inside voice while in the building and transition safely in between class time, lunch time, specials, and other settings. Client is observed making better choices and doing the right thing. Client has improved with staying in class and utilizing his breaks appropriately without needing to displaying attention seeking behaviors to get his way. Client has difficulty staying focused when distracted by others who are off task and has to be reminded to get back on track. Client responds well to praise and support. Client is acceptive of redirection. Client understands that his actions have consequences. Client is striving for a good report from school everyday. Client wants to make his teacher and parents proud by doing a good job. Client is very independent but can be a team player as well. Client reviewed last week discussion with psycho educational group and retained a lot of the information he was taught which motivates his group to pay more attention and take their time. Client is observed problem solving on his own and handling his emotions appropriately. Client avoids meltdowns and lashing out when upset or frustrated. Client responds well to feedback. Client responds well to the positive reinforcement provided by QMHP and is seen increasing self-esteem and confidence. Client said he was going to practice coping strategies and relaxation techniques in all aspects of his daily living routine in hopes that he will be a better person, student, sibling, and friend.