5/16/2023 EnchantaVaughn Approved (AM) Upon arrival, client started the day off on a bad note. Client continues to display inappropriate social behaviors, showing no interest in being in the classroom at this time. Client was not polite or courteous to his substitute teacher and displayed disruptive behaviors all morning. Client failed to listen and follow directions and was observed horse playing and interacting aggressively with his peers. Client was seen running around, making noise, and being silly. Client was not focused on the morning activity and had a hard time staying seated. Client was sent to his counselor for redirection. Client was given a 30 minute break to self-reflect and reduce hyperactive and impulsive behaviors. Client was able to calm down and return back to class without incident. Client was on task and following class rules. Client adjusted himself in his seat so that he could see and give good eye contact to his teacher. Client was observed completing a worksheet packet and using good voice volume. Client exhibited positive communication with peers and took initiative to pass out supplies. Client was well behaved and preparing for lunch. (PM) As the client transitions to lunch he is seen in line, keeping his hands to himself, and walking quietly. Client entered the cafeteria and stood in line to wait for his food. Client was able to sit at his table and enjoy his lunch without getting in trouble and giving others good personal space. Client displayed the correct manners at the lunch table throughout lunch time and was given a thumbs up by mental health professional for turning his day around. Client joined his class for recess and specials and needed no additional redirection. Client was observed in social settings adhering to the rules and regulations and working well with others. Client participated individual and group work without complaining or having an attitude and the sub was appreciative of his effort and respect giving him praise and writing a good report to his teacher. Client displayed good social skills by sharing and taking turns, indicating he know how to be a team player. Client was able to control negative behaviors, despite stressful environment and display kindness and empathy toward his peers who were having a bad day. Client demonstrated team work and independence. Client went back into academic setting with a pleasant attitude also displaying good energy and being respectful of authority. Client expressed happy thoughts by smiling and laughing with peers and preparing for the next activity. (EOD) Client was observed in class listening to instruction and ready to learn. Client ignored distractions while completing his work and the benefits of this were reviewed. Client was able to finish the day without aggressive or defiant behaviors. Client displayed appropriate interaction with peers. Client displayed appropriate conduct in the classroom. Client stayed in his seat, contributed to discussion, and finished his assignments. Client was cooperative during each activity and was able to maintain good behaviors and classroom management. Teacher reported client is okay when no one is messing with him and can be a good boy if he focuses on himself and stays in his seat. Client was recognized for displaying good behaviors and meeting objectives 1 and 2 but failed to obtain objective 3, due to impulsiveness and lack of control of behaviors. (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.