5/12/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed in a frustrated mood, as evidenced by his facial expressions and brushing off QMHP. Client was pulled to the side and confronted about his atitude. Client shrugged his shoulders and rolled his eyes. Client was prompted to be more respectful and turn his face around. Client responded to the third prompt and started to straighten up. Client was able to deep breathe and decrease frustration. Client headed to class to start his day. Client struggled to stay in class and do his work. Client was hyper aggressive in group setting and needed some alone time, symptoms which directly correlate to his current diagnosis of Attention Deficit Hyperactive Disorder. Client displayed restlessness and was unfocused during group. Client became increasingly non-compliant with prompts and directives given by both mental health professionals. Client displayed restless displays of behaviors even after one on one. Client processed his feelings and started to make better choices. Client decided to draw pictures of his favorite places and this activity put him in a better mood. (PM) Although, client has been with his counselor for most of the day, counseling has benefited him and given him a space to reflect and cool off. Client stayed with his counselor during lunch to prevent any misbehavior or giving his teacher a hard time. Client feels his teacher do not want him back in class. Client was encouraged to think about ways to apologize for his mistakes without verbalizing it. Client was supported with turning his day around. Client did a good job reducing his aggressive behaviors and being less upset over nothing. Client has not maintained appropriate conduct and helping others who needed help. Client struggles with coping with stressors and staying alert in class. Client is often distracted by his own thoughts. Client's teacher gave him a choice to come back in class and listen and pay attention or sit in the office. Teacher was not happy with client choosing to stay out of class all day. Client was reasurred that his teacher wants the best for him and is there to help him. Client is encouraged to reach out to his teacher when he has a problem and to be open about how he feels. Client was able to take in the positive encouragement and act more responsibly. Client went into class willing and ready to learn. (EOD) Client was acceptive to redirection and returned to class in a cooperative manner. Client was able to let go of unwanted feelings and show respect to group by participating and acknowledging positive feedback. Client is observed displaying good behaviors. Client was able to reframe from impulsive, hyperactive behaviors until dismissal. Client utilized the last part of his day to catch up on the review and to organize his testing material so that he could finish studying at home. Client expressed good communication and was applauded for being in class and on task. Client hugged QMHP before leaving, displaying a great attitude. Client was unable to succesfully obtain his objectives today, as observed. (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.