5/15/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed sitting quietly in his seat displaying positive social behaviors during morning announcements. Client appeared to be in an excited and upbeat mood as evidenced by him smiling and initiating a conversation with QMHP. Client expressed that he was feeling good and was going to have a good day. Client shared positive thoughts about his morning and continued making good choices, which were supported by QMHP and teacher. Client was observed practicing his calming and relaxation strategies by utilizing building blocks and puzzles to exercise his mind and work on his personal strengths (i.e. counting and competing with his best self). Client demonstrated good teamwork skills and leadership capabilities by offering some of the games to his classmates and taking turns sharing the blocks and puzzles. (PM) Client transitioned to the cafeteria in a pleasant manner, being respectful to peers and staff as he waited in line for lunch. Client stayed on task and conducted himself well at the lunch table. Client was witnessed throwing away his trash and walking over to his counseling session. Client was observed to interact with peers and mental health professionals in a quiet and respectful manner. Client informed QMHP that he practiced his self-coping techniques while at home. Client participated in all prompts and directives of QMHP and mental health professionals. Client was observed practicing positive behaviors and making good decisions by QMHP and mental health professionals. Client stated he wanted to go back to class after taking a 10 minute break. Client was escorted to class with peers and supported with using his inside voice and manners. (EOD) Teacher reported, client required 1-2 prompts of redirection before he followed through. Client displayed restlessness and was unfocused during classroom activities. Client was prompted to refocus 3-4 times by teacher. Client was moved to a different seat in hopes he would regroup and refocus. Client was observed adhering to ISP objectives 1, 2 and 3 by QMHP. Client was monitored attempting to refrain from being involved in horseplay and drama. Client raised his hand to ask for permission before leaving his seat. Client was able to exhibit positive social behaviors amongst his peers as well as mental health professionals. Client was friendly and exhibited a pleasant demeanor. Client was observed openly expressing his preferences to peers and mental health professionals as he was prompted to give his insight into an activity. Client prepared for dismissal and announcements, packing his belongings and exiting the classroom. Client met objectives, as evidenced by his management of individualized behaviors and avoiding altercation. (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 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.