7/28/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed entering the summer program building in a hyperactive mood, as evidenced by him jumping around and being playful in the hallway. Client took a basketball out of his book bag and began horse playing, disrupting others who were trying to learn and enjoy their morning. Client was prompted to put the ball away but he refused. Client threw a temper tantrum for a few minutes then pouted and frowned up his face at school staff who were trying to assist and redirect his attention. (PM) Client was observed in lunch having a good time and enjoying his food along side his classmates. Client presented himself in a good mood, as evidenced by him dancing and engaging in conversation with peers. Client was monitored and supported with listening to lunch staff and cleaning up his trash to prepare for another transition. Client was seen lining up with his class to take a bathroom break. Client stopped by to see QMHP and take his break. Client was calm and relaxed and doing a good job, at this time. Client earned a treat for being able to be a big boy earlier and showing he can be a responsible student and do his part without needing constant redirection. (EOD) Client was sent home early due to conflict with his hometown teacher. Teacher reported client called her over 20 x’s from a cell phone and she had to block the number with her carrier to prevent him from continuing to call. Teacher was not happy with his actions and attempt to reach her outside of school hours. Mom was contacted and asked to pick up client after lunch. Client left school for half a day, failing to meet goals and objectives. (AM) QMHP welcomed client to summer program 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.