5/15/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed entering class in a uptight mood, as evidenced by him cringing up his face and frowning. Client presented a negative attitude toward his teacher and counselor due to being upset that he had to deal with the consequences of his actions. Client was standoffish and distant, ignoring debriefing and refusing to communicate his feelings when inquired about his morning. Client avoided all contact and returned to his class to finish his work. Client was observed at his desk off task and engaging in inappropriate activity. Client was not attentive or listening to the teacher and was asked to take a break. Client is seen walking quietly in the hallway and preparing for psycho educational. (PM) Client was not productive when QMHP walked in his class to check on him during evening academic hours. Client was seen at his seat not working. Client threw his coat, book bag, and hat on the floor when he got irritated with his assignments. Client seemed like the only one not happy or satisfied, meanwhile the other kids were laughing and playing. Client was inquired why he was sitting in the back of the class in a downward mood. Client just looked up without saying a word. Client displayed fidgety behavior and tried to blame others for his low motivation in the school setting. Client was educated that it is his responsibility to get his work done and to raise his hand when he needs help. Client was prompted to take a break and cool off. Client did not do a good job walking down the hallway. Client was caught several times running and jumping. Client prepared for psycho educational. Client displayed moderate participation. Client demonstrated poor listening skills. Client is very talkative and is easily angered by others success. Client displays attention-seeking behaviors, 2-3x, moderate to intense. Client was given redirection by both male and female mental health professionals and directed to get back on task. Client calmed down and was able to join his group in the gym to play ball. (EOD) Client was monitored in individual setting listening and displaying low level of participation. The client was taught alternative ways of expressing negative emotions (e.g. writing, drawing, physical activity, or talking to a friend) but the client’s psychotic thinking persists, despite the use of coping skills and other interventions, and he was provided with additional support in this area. The client do not like to admit what he does wrong and constantly gives authority figures a hard time. Client have not utilized healthy coping practices and was urged to do so. The client has a difficult time transitioning from setting to setting due to his relationship with different staff members. Client is unable to identify many significant positive hopeful things in his life and is provided with examples of those. As the client prepared for dismissal, he was observed sharing and being fair to others. Client remained in class and was able to refocus his attention to more favorable acts of kindness, achieving objective 2 but failing to achieve objectives 1 and 3, as evidenced. (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 monitored client individualized behaviors in collaboration with his teacher and other mental health professional. QMHP encouraged client to make good choices and to utilize self calming techniques (i.e. counting and deep breathing) and processed with him that this behavior is acceptable and discussed actions and consequences. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. (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 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 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. (EOD) 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 encouragment. 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. QMHP will educate client on behavior modification to help client identify what behavior he need 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 greeted QMHP by saying good morning. 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. Client said he was going to have a good day and decided to practice yoga poses with group member before returning to class. 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 nd count to 10. Client said he went to a boys and girls club program after school and enjoys playing basketball with his peers. Client was reported displaying age appropriate behaviors and was productive and studious in class. (PM) Client said thank you and continued to do what he was told. Client demonstrated responsibility and leadership. Client was acceptive of redirection. 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. 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 met with QMHP to discuss progress, setbacks, and improvements. Client understood what he needed to change and planned to fix his mistakes.