1/18/2023 EnchantaVaughn Approved (AM) Upon arrival, client exhibited positive behaviors and showed excellent conduct during morning annoucements. Client seemed to be in a positive mood, as evidenced by his pleasant spirit and upbeat tone when speaking to QMHP. Client demonstrated he was happy to be in school. Client was observed participating in classroom activities without hyperactive or impulsive behaviors. Client was reported to be on track with goals and objectives and displaying age appropriate behaviors. Client was observed in class adhering to rules and expectations. Client was seen communicating positive feelings and initiating conversation with the peers at his table without interrupting teacher who was teaching the lesson. Client was observed following directions and on task, indicating he was going to have a great day. Client was in a restless mood, as evidenced by his tense facial expressions and anxious demeanor. Client was supported with sitting in his seat and paying attention to morning activity. Client appeared to be implementing pro social behaviors by displaying ability to work as a team avoiding distractions. Client was very polite toward peers and authority. Client exhibited high level of participation, completing his assignments, and transitioning smoothly into pm settings (e.g. lunch, psycho educational, and recess). (PM) Mom surprised client with lunch today. Client looked very happy to see mom. Client verbalized positive thoughts about his day and appeared to be enjoying himself in lunch. Client was well mannered throughout the day and recognized by his teacher for doing a wonderful job with learning and being attentive. Client demonstrated a great attitude and was involved in team building exercise to engage with his peers. Client expressed insightful comments during group discussion and was respectful to authority. Client was rewarded for his hard work and encouraged to keep up the good work. Client was engaged into his work today, reframing from all distractions. Client was able to transition and recognize his anger triggers by associating himself with the right crowd and staying focused on achieving his goals and objectives. Client expressed excitement to see QMHP by giving her a hug and reflecting on his day. Client appeared to grasp understanding of accepting the responsibilities of his actions by encouraging his peers to do the right thing. Client was praised for his commitment in building new and healthy relationships in school. Client displays leadership skills in the classroom setting and is always volunteering to help his teacher. Client was observed exhibiting appropriate behaviors and having a good attitude. (EOD) Client expressed positive communication with mental health professional, talking about his day and how well he was doing in class. Client appeared to be in an exquisite mood, as evidenced by his genuine smile and energetic spirit. Client was happy to be around peers that were nice and welcoming for a change and not experiencing students picking on him in class. Client is observed supporting his classmates during a group activity and offering positive feedback. Client was praised for her cooperation and efforts, ending the day achieving all objectives. (AM) QMHP had one on one with client. QMHP will conduct a morning session to debrief and talk about yesterday's events. QMHP provided support and encouragement to ensure goals and objectives are met. QMHP initiated a rapport building conversation with client in efforts to learn more of his likes and dislikes as well as triggers to negative behaviors listed on his ISP. QMHP will review key concepts of being a responsible student with the group. QMHP will educate client about being respectful, encouraging, mindful, and fair to peers and authority while making good decisions in school. 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, as well as, simple praises and encouragement to continue the positive behaviors he was exhibiting. QMHP modeled pro-social behaviors for client to strengthen his understanding of them. QMHP engaged the client in a role reversal exercise and required the client to think about his goals for the upcoming school year. QMHP commended Client on utilizing coping strategies to increase his understanding of feelings and emotions. QMHP intervened to prevent the negative behaviors from escalating. QMHP physically redirected client to an alternative activity. QMHP provided guidance on alternative behaviors and clear instruction on the alternative behavior. QMHP provided positive feedback when client engaged in the more appropriate behavior. (PM) QMHP will collaborate with teacher regarding behaviors and performance. QMHP will review and give feedback regarding ADHD and its causes and affect toward his well-being and academic functioning. QMHP will monitor, observe, and redirect client behaviors as needed. QMHP monitored client individualized behaviors in collaboration with his teacher, peers, and environment. QMHP encouraged client to make good choices and to avoid negative thoughts about himself. QMHP processed client positive behaviors. QMHP assisted client in developing more social skills. QMHP inquired about possible challenges client can experience with applying this skill. QMHP provided positive feedback. QMHP reflected on client goals and objectives. QMHP isolated client from distractions to decrease disruptive behaviors and to reduce episodes. QMHP assisted client in normalizing the changes that are occurring in school. (EOD) 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 needs to decrease and avoid daily. QMHP will utilize behavior modification system to aid the client with following directions given by authority figures. QMHP explored the client’s capability to cope with his stressors and to get back on track. QMHP modeled the correct behaviors and conduct during quiet time. QMHP assisted client with finding and utilizing necessary resources. QMHP verbalized the awareness that all people are unique, learn differently, and have various strengths and weaknesses. (AM) Client will have one on one with QMHP in morning, afternoon, and end of the day to reflect and process feelings about his day. Client communicated positive affirmations and self-talk. Client shared some of the things he does at home to help him relax. Client stated he loves playing outside after school. Client participated in reviewing key concepts. Client showed good understanding of what it means to be respectful, encouraging, mindful, and fair to others. Client is observed correcting his mistakes and making good choices. Client was able to utilize coping skills to eliminate stressors and unwanted feelings. Client displayed self determination to stay focused and pay attention in class. Client utilized meditation and relaxation techniques. Client was seen decreasing anger and frustration. Client reported a decrease in symptoms following the relaxation techniques. Client verbalized positive feelings about building relationships in school. Client displayed management of individualized behaviors. The client has not overreacted with anger to minor frustrations or irritants. Client responded in a pleasant manner acknowledging the positive reinforcement that the QMHP provided. (PM) Client discussed mental illness and its causes as a group. Client displayed interest in learning about ADHD. Client believes he will get better grades in school by staying in class and listening to his teacher. Client was acceptive of support and encouragement. Client exhibited good social behaviors. Client was able to reevaluate himself and display a more positive attitude toward peers and authority. Client has become more involved in age appropriate social activities and was given positive reinforcement for these choices. Client demonstrated expectations and responded well to feedback. Client reported a decreased stress level due to his modulation of social contact, and the success of this was reviewed. (EOD) As the client developed understanding of academic expectations, he reported increased satisfaction and function. Client responded well to feedback, interacting well with others. Client implemented his plan for restoring relationships, and this was reviewed. Client acknowledged QMHP and explored his options. Client proceeded to reduce the aggression in his voice while calming down. Client accepted suggestions from QMHP as evidenced by the client smiling and saying thank you. Client displayed positive self-talk, ability to follow instructions, role play of appropriate way to act in school, increased communication and exhibiting the positive reinforcers that were provided by QMHP. Client has implemented the correct behaviors in class toward authority figures and classmates. Client was observed avoiding disruptive and impulsive actions demonstrated when client proceeded to walk away from peers who were involved in negative behaviors. Client acknowledged QMHP's praise by saying thank you. Client was observed intervening and regulating his emotions. Client was able to demonstrate fairness and kindness to peers and authority. Client provided several scenarios for QMHP to model positive prosocial behaviors within. Client was able to detect and acknowledge both positive and negative responses modeled by QMHP. Client knows what he needs to do to improve socially and academically. Client expressed to QMHP that he understood the importance school and promised to do a better job. Client dismissed without incident.