2/28/2023 EnchantaVaughn Approved (AM) Upon arrival, client looked happy and ready for the day as evidenced by his excitement and compassion with getting to class before the bell rung. Client entered his class in a smooth and polite manner. Client was seen preparing himself for the morning announcements and teacher to start the lesson. Client took out a pencil and waited for instructions. Client was seen conversing with his peers and practicing responsibility by encouraging them to sit down and pay attention. Client displays leadership skills in the classroom setting and is always volunteering to help his teacher in any way. Client was observed exhibiting appropriate behaviors and being a team player. Client was supported with staying on task and being a team player. Client appeared to be in a content mood, as evidenced by his straight facial expressions and positive body gestures. Client looked very focused and alert at his desk. Client displayed appropriate social skills and showed good mannerisms until it was time for lunch. (PM) Client was reported arriving in an optimistic mood and displaying appropriate manners on the way to class. Client was seen modeling safety plan by being observant to his surroundings and separating himself from undesirable behaviors (e.g. talking out of turn and leaving area without permission). Client was having appropriate conversation with peers. Client was respectful of his teacher. Client was helpful to his peers, as evidenced by him sharing school supplies and personal belongings during the group activity. Client displayed good active listening skills. Client was encouraged to express himself and be confident about his answers. Client returned to his seat with a positive 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 see his group of friends and supported them during group activity. Client displays an increased pattern of independence through engaging in school activities. Client is making better choices as he heads into the later part of the day. Client showed excellent problem solving skills by challenging himself to work independently without depending on others for help. Client was cooperative until dismissal. Client was praised for his cooperation and efforts ending the day achieving objectives 1, 2, and 3. (AM) QMHP greeted client and praised his positive interactions at school. QMHP listened as client provided feedback concerning his anxiety. QMHP challenged client to think positive thoughts. QMHP inquired about his morning routine. QMHP actively listened to client express his needs and wants. QMHP commended client for his positive communication modeled in class without displaying aggressive or defiant behavior. QMHP utilized behavior modification by verbally instructing client to relax his voice and calm down when he gets upset. QMHP assisted client in monitoring his own behaviors in efforts to promote exercising self-control in focused areas such as respecting boundaries with others. QMHP modeled proper positive behavioral expectations for the client to apply in social and non-social environments. (PM) QMHP assessed client's behaviors and mood in specials, lunch, and recess. QMHP communicated with client on displaying appropriate control. QMHP probed client about certain behaviors and how he sometimes feels like the only way to respond is in a negative manner. QMHP verbally identified the client's impulsiveness to the client and encouraged the client to use self control and decrease hyperactive behaviors. QMHP introduced concept of nonverbal communication cues in efforts to review the expected behaviors or results to the nonverbal cues. QMHP continued to engage with client and provided positive reinforcement as he participated in the session. (EOD) QMHP discussed anxiety and explained it is normal part of life. QMHP provided examples of anxiety inducing situations. QMHP provided a list of experiences that is common with his mental illness. QMHP challenged client to identify any situation he has experienced. QMHP further explained different situations that can cause anxiety, such as the fear of asking for help. QMHP provided feedback regarding client inquiries with other subjects. QMHP continued to establish a positive supportive relationship with client. QMHP offered simple suggestions to the client for behaving appropriately in the community and encouraged client to practice the positive behaviors at home and at school. QMHP encouraged client to participate in desirable behaviors for the entire day. QMHP informed client that he needed to regulate his anger outbursts in efforts to reduce them and work towards achieving his ISP objectives for the day. QMHP continued to elaborate on ways client can cope and manage stressors at school, home, and in the community. (AM) Client smiled as he was affirmed for his mature and pleasant behaviors. Client informed QMHP that he was coping and utilizing deep breathing techniques to stay calm and not overreact to minor irritants. Client was able to recover and adjust his negative behaviors to a more positive and constructive manner throughout the morning debrief with mental health professional. Client was receptive and open towards the positive reinforcement provided by QMHP. Client struggled to identify his stimulus that triggered his frustrated and angry emotions, indicating that he is unaware of his inappropriate behaviors. Client appeared sincere and apologetic, as he followed the instructions of the QMHP. Client was able to decrease his overactive and angry behaviors within a few minutes of redirection. Client was receptive and approachable during the first half of the day, extending a welcoming rapport back to the QMHP and his teacher. (PM) Client initially presented with talkative behaviors as he probed the QMHP and asked different questions. Client began to display positive thoughts throughout the session. Client was receptive and open to the interventions, as he was attentive and focus on the information and activities that were being processed without any difficulties. Client appeared to have a clear knowledge of the interventions. Client was sociable and friendly in regards to the QMHP’s positive empathy. Client was able to express and explore his perceptions of relationship skill building. Client complied and went over ISP objectives with QMHP with no resistance. Client stated he was going to achieve his goals today. (EOD) Client was able to relax and regain and regulate his overactive behaviors. Client demonstrated moderate progress with asking for help. Client was able to communicate with the QMHP in a respectful and polite manner. Client communicated that he felt safe and comfortable talking to his TDT counselor more than some of his teachers. Client understood that he is responsible for confiding in other adult figures for support and giving them the chance to help him as well. Client was fully engaged in the conversation with his peers and making insightful comments. Client showed initiative with doing a better job with coping and managing stressors without attention-seeking behaviors or acting out of character. Client dismissed from school without incident, reearning points he lost on his dojo and showing commitment with reducing his temper.