5/11/2023 EnchantaVaughn Approved (AM) Upon arrival, client appeared to be in a standoffish mood as evidenced by his closed body language and looking away when greeted by QMHP. Client was inquired about how he was feeling. Client communicated he was a little tired and haven’t ate breakfast yet. Client was given a snack and sent to class to begin morning work. Client seemed to be having a much better day following yesterday’s events. Client was observed following directions and maintaining a positive attitude. Although having difficulty coming to group therapy, client was assisted in identifying positive, realistic self-attributions about himself and advised to give his full undivided attention. (PM) Client seem to be irritated and needed a second to cool off before processing. Client disliked having to be in class for most of the day and requested to see his counselor. Client required one on one before he followed through with authority directives and prompts. Client appeared to benefit from therapeutic breaks, as observed reducing unwanted feelings. Client was able to transition into lunch and stand with his class. Client was observed handling himself well around others without initiating conflict. Client displayed a positive attitude going into specials. (EOD) The client was reinforced regarding his ability to cope with negative feelings about self without feeling threatened. Client is supported with appropriately asking for help. Client displays a really low confidence level when it comes to sharing his feelings but can identify feelings outside of his own. Client is encouraged to engage in self-reflection and allow himself to release any tension built up and to work on it one day at a time. Client was hyper aggressive and continuously shouted inappropriate statements to his peers and mental health professionals; symptoms which directly correlate to his current diagnosis of Attention Deficit Hyperactive Disorder. Client partially met objectives, due to needing improvement with maintaining control of impulses and complying to instructions when faced with fear, stress, or anxiety. (AM) QMHP had one on one with client. QMHP reviewed yesterday's activities. QMHP provided support and encouragement to ensure goals and objectives are met. QMHP monitored client individualized behaviors in collaboration with his teacher and social environment. QMHP encouraged client to make good choices and to avoid negative thoughts about himself. QMHP processed client positive behaviors. (PM) QMHP assited 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 occuring in school. (EOD) 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 session 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 communicated positive affirmations and self talk. 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 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.