5/9/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed displaying positive social behaviors in the classroom. Client was in a fantastic mood, as evidenced by his energetic and fulfilled spirit. The client was supported for displaying an understanding of the social skills that were reviewed. Client verbalized positive I statements by saying “I feel good” and “I will have a good day”. Client was monitored in his seat and following directions. Client was praised and encouraged to keep up the good work. Client was observed displaying age appropriate behaviors and interacting well with his peers. Client expressed happy expressions and was respectful to his teacher and mental health professional. Client demonstrated excellent team work and responsibility by sharing and staying on task. Client headed to his library specials to begin a reading activity. Client exhibited active listening skills. Client was seen following directions and on track with goals and objectives. Client transitioned smoothly to lunch. No redirection was needed at this time. (PM) Client was seen at lunch interacting well with his classmates and friends. Client seemed to be in a content mood and enjoying lunch. Client exhibited great teamwork skills and demonstrated he can be a good listener. Client expressed a good attitude and worked together with his group member to explore new opportunities of learning. Client showed his appreciation to counselor by saying “please and thank you”. Client was observed helping others and smiling and laughing. Client returned to class to finish his work and was on task and attentive to his assignments. (EOD) As the client continued to have a wonderful day, he was praised for all of his hard work and improving his behaviors without getting upset or frustrated. Client displayed no symptoms of ADHD as it relates to impulsivity and defiance, exhibiting good self control. Client was observed adhering to school rules and preparing for dismissal, by clearing off his desk and packing up his belongings. Client was able to obtain all objectives. (AM) QMHP had one on one with client. QMHP explored positive behavior options he was exhibiting with client to support his willingness to continue to make good decisions and display appropriate behaviors in school. QMHP processed thoughts and feelings. QMHP inquired about morning routine and previous activities. QMHP encouraged client to utilize positive self talk as a means of decreasing anxiety and managing frustration when encountering difficult or challenging circumstances. QMHP talked to client about his confidence levels and how they can affect his day and self esteem. QMHP encouraged client to make good choices. QMHP monitored acquisition of behaviors and managing individualized behavioral modification programs. QMHP provided simple praises to client in efforts to motivate client to have a good rest of the day. (PM) QMHP supported client with building new relationships in lunch and interacting with his age group. QMHP assisted client with breathing and relaxation exercises in efforts to reduce symptoms of ADHD. QMHP utilized behavior modification strategies including removing client from the stimulant and stressful environments in efforts for him to reduce impulsive and defiant behaviors. QMHP assisted client in exploring other coping strategies that he had previously used to solve problems and avoid conflict. QMHP observed client in academic and social settings throughout the day to determine the need for redirection. (EOD) QMHP reminded client of goals and objectives and what things he can improve in order to successfully meet ISP. QMHP held consultations with client and teacher about effective intervention strategies that build on the client’s strengths and compensate for his negative behaviors. QMHP encouraged teachers to provide frequent positive reinforcement to maintain client’s interest and motivation in maintaining positive classroom behaviors and completing his school assignments. QMHP reviewed the reported behaviors with client in efforts to allow him to express his point of view and self reflect. QMHP did not have to prompt or intervene any negative behaviors during dismissal, as he demonstrated adherence to classroom rules and expectations. (AM) Client greeted mental health professional by waving and smiling. Client said good morning upon arrival and grabbed breakfast to prepare for his day. Client demonstrated excellent social skills due to positive interaction with peers and helping others. Client expressed he was feeling good. Client stated he wakes up on time for school but has a hard time going to bed on time due to playing video games and watching tv. Client admitted that losing out on sleep is not good for his health or education. Client communicated good “I statements”, such as, “I will be a leader” “I will show respect” “I will do my work and listen to my teacher”. Client expressed low confidence when talking about things he dislikes and other challenging tasks. Client explained he likes to be rewarded and praised by others. Client promised to do the right thing. Client was observed following directions and participating in class. Client said thank you and returned to his seat. (PM) Client seems to enjoy making new friends in school. Client interacts well with his peers unless he feels bullied. Client often follow behind others who are being disruptive and has to be reminded to get back on task. Client utilized breathing and relaxation techniques during therapy session and free time in class. Client was able to reduce hyperactive behaviors with additional support and redirection. Client is seen dealing with stressors and coping appropriately. Client utilized conflict resolution skills in school by problem solving on his own and compromising with his peers. (EOD) Client reviewed goals and objectives. Client admitted he needs improvement and plans to practice skills and strategies at home in order to stop complaining about doing work in school. Client was able to eliminate unwanted behaviors and implement new strengths. Client benefited from positive reinforcement. Client engaged in self-reflection and role-playing activities to correct his mistakes. Client demonstrates excellent conduct at this time while displaying responsible behavior, ending the day on a good note.