1/2/2024 EnchantaVaughn Approved (AM) Upon arrival, client was supported with being in class and contributing to his class assignments. Client recieved a compliment from his teacher for answering questions on the board during breakfast and paying attention to his morning work while others were off task. Client was congratulated for his excellent behaviors and productivity in class. Client seemed to be enjoying his morning, communicating positive social behaviors (e.g. keeping his hands to himself and giving his peers personal space). Client displayed good active listening skills. Client was encouraged to express himself and be confident about his answers. Client displayed a calm and positive attitude. Client exhibited good teamwork. Client showed creativity with his assignments by utilizing his fingers and memory to figure out math problems. Client was given a thumbs up by his counselor for his exceptional work in class and doing a wonderful job being more involved with his academics and striving to make good grades this year. Client was happy to be noticed and recognized for his hard work, as seen smiling and smirking in his seat. Client continued to focus on his work and try his best to work independently, requiring little to no assistance at this time. (PM) Client was supported for not being disruptive to others and decreasing impulsivity. Client was able to transition to the cafeteria in a positive manner, speaking to QMHP with a friendly tone and walking quietly in the hallway. Client was observed interacting well with his peers and engaging in proactive hobbies (e.g. rock, paper, scissors and counting). Client demonstrated positive social behaviors throughout the day, reframing from altercation and verbal/physical conflict. (EOD) Client is making progress with his goals and objectives, as evidenced by him learning new ways to resolve conflict with his teachers and peers. Client appeared to be in a good mood, as evidenced by his positive facial expressions and ability to reframe from all distractions. Client models great listening skills when it is not his turn to speak. Client raises his hands when he has a question. Client understands that it is his responsibility to be a good student and follow directions. Client states that he is going to have a good rest of his day and utilize his relaxation techniques when he needs recoup. Client displays excellent behavior in school and earned points for being persistent, working well with others, showing positivity during transition, being polite to staff/teachers, and exhibiting responsibility in the classroom setting, as reflected on his dojo cart. No incidents reported, confirming client met ISP objectives. (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 inquired about weekend activities, asking what was exciting about your week. QMHP inquired about morning routine at home before coming to school. QMHP monitored client individualized behaviors in collaboration with his teacher and other mental health staff. QMHP encouraged client to make good choices and to utilize self calming techniques (i.e. counting to 10 and deep breathing skills) and processed with him about weekly behaviors, the good and bad, as well as, expectations. QMHP challenged client to continue displaying a positive attitude while employing positive reinforcement when client is able to achieve his goals and objectives. QMHP will teach client positive outlets and identify anger triggers. QMHP will assist client with developing effective focus techniques. QMHP will role play and demonstrate appropriate ways to interact with adults. (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 will teach positive alternatives to deal with anger. QMHP will provide opportunities for positive age communication. QMHP will verbally process with client ways to display improved impulse control. 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 offered help. QMHP encouraged client to continue having a good day. (EOD) QMHP monitored for acquisition of objectives. QMHP redirected client negative behaviors. QMHP encouraged client to stay in class and comply to rules and directives. QMHP encouraged client to be the example. QMHP encouraged client not to follow others that he see are doing wrong. QMHP intervened to assist in explaining behaviors to client. QMHP reflected with client on his day, both happy and frustrating experiences. QMHP encouraged client that tomorrow is a new day. QMHP processed client feelings. QMHP engaged in active listening. QMHP assisted client with recognizing his own personal strengths and how to apply them to reach his goals and objectives daily. QMHP reviewed several strategies for conflict resolution and positive social behaviors with client in efforts to increase client’s awareness. QMHP provided simple praises to client for his commitment to his progress. (AM) Client greeted QMHP by saying good morning. Client reflected on his weekend activities. Client said he woke up feeling good and was ready to have a good day. Client expressed positive thoughts about himself. Client stated he didn't need help with anything at the moment but would tell an adult if he needs help. Client communicated by nodding and exhibiting good eye contact. 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. (PM) Client said thank you and continued to do what he was told. Client said he was going to have a good day and decided to practice yoga poses with group member before returning to class. 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 was displaying respectful, non aggressive behaviors in lunch. Objectives were being met at this time, dispite stressful environment. Client demonstrates full understanding and capability of decreasing his symptoms associated with his mental illness and increasing his level of thinking, so that he can meet his objectives and make the right choices. Client appeared to be in a more calm mood, as evidenced by his upbeat spirit and enjoying himself during the activity. (EOD) Client avoided distractions in social setting, while utilizing anger management skills. Client seem to have a big influence on his peers. Client displays leadership skills by helping others and being a good citizen in school. Client acknowledged interventions and verbalized clear understanding. Client engaged in reflective thinking. Client communicated the do's and don'ts. Client was in a pleasant mood after feedback was given. Client was seen having a good evening. Client was able to identify the role he plays in each situation and continues to comply with authority rules and regulations. Client remembered to apply himself and utilize his strengths to focus on meeting his goals and objectives. Client administered positive behavioral expectations, reducing symptoms associated with his ADHD.