10/31/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed in class attending to morning specials. Client seemed to be in a good mood, as evidenced by his content and happy expressions. Client displayed appropriate behaviors while interacting well with others. Client participated in individual and group activities without getting frustrated, and support was provided. Client communicated the positive reinforcement that was provided by TDT staff. Client is seen helping others and cleaning up behind himself. Client displays appropriate gestures in the hallways by walking one behind the other and facing forward. (PM) Client was seen in lunch displaying good social behaviors by standing quietly in line and picking up food without hyperactive behaviors. Client demonstrates good sportsmanship by keeping his hands to himself and avoiding conflict. Client was praised for displaying a positive attitude around his peers. Cafeteria monitors prompted client to put his head down once he finishes is lunch so that everyone can enjoy their lunch time without being interrupted. Client was observed following rules and expectations. Client was observed listening to authority and waiting patiently for teacher to dismiss them. Client transitioned smoothly to psycho educational to begin session. (EOD) Client developed good understanding of this week’s psycho educational. Client utilized acquired skills learned in therapeutic day treatment to focus on his work and make good choices. Client was observed displaying calm, non-aggressive behaviors around peers and authority. Client appeared focused and undistracted by others who were off task. Client was observed working well with his group and being respectful to mental health professionals. Client returned to class with a positive attitude and went straight to his seat to join his class in a reading activity. Client displayed little to no impulsivity and was witnessed paying attention in class while teacher was teaching lesson. Client was seen preparing for dismissal and packing up quietly. Client was able to obtain ISP objectives, as evidenced by successfully adhering to rules and expectations in the school setting. (AM) QMHP had one on one with client. QMHP explored positive behavior options he was exhibiting with client to support his willingness to continue to make good decisions and display appropriate behaviors in school. QMHP processed thoughts and feelings. QMHP inquired about morning routine and previous activities. QMHP encouraged client to utilize positive self talk as a means of decreasing anxiety and managing frustration when encountering difficult or challenging circumstances. QMHP talked to client about his confidence levels and how they can affect his day and self esteem. QMHP encouraged client to make good choices. QMHP monitored acquisition of behaviors and managing individualized behavioral modification programs. QMHP provided simple praises to client in efforts to motivate client to have a good rest of the day. (PM) QMHP supported client with building new relationships in lunch and interacting with his age group. QMHP assisted client with breathing and relaxation exercises in efforts to reduce symptoms of ADHD. QMHP utilized behavior modification strategies including removing client from the stimulant and stressful environments in efforts for him to reduce impulsive and defiant behaviors. QMHP assisted client in exploring other coping strategies that he had previously used to solve problems and avoid conflict. QMHP observed client in academic and social settings throughout the day to determine the need for redirection. (EOD) QMHP reminded client of goals and objectives and what things he can improve in order to successfully meet ISP. QMHP held consultations with client and teacher about effective intervention strategies that build on the client’s strengths and compensate for his negative behaviors. QMHP encouraged teachers to provide frequent positive reinforcement to maintain client’s interest and motivation in maintaining positive classroom behaviors and completing his school assignments. QMHP reviewed the reported behaviors with client in efforts to allow him to express his point of view and self reflect. QMHP did not have to prompt or intervene any negative behaviors during dismissal, as he demonstrated adherence to classroom rules and expectations. (AM) Client greeted mental health professional by waving and smiling. Client said good morning upon arrival and grabbed breakfast to prepare for his day. Client demonstrated excellent social skills due to positive interaction with peers and helping others. Client expressed he was feeling good. Client stated he wakes up on time for school but has a hard time going to bed on time due to playing video games and watching tv. Client admitted that losing out on sleep is not good for his health or education. Client communicated good “I statements”, such as, “I will be a leader” “I will show respect” “I will do my work and listen to my teacher”. Client expressed low confidence when talking about things he dislikes and other challenging tasks. Client explained he likes to be rewarded and praised by others. Client promised to do the right thing. Client was observed following directions and participating in class. Client said thank you and returned to his seat. (PM) Client seems to enjoy making new friends in school. Client interacts well with his peers unless he feels bullied. Client often follow behind others who are being disruptive and has to be reminded to get back on task. Client utilized breathing and relaxation techniques during therapy session and free time in class. Client was able to reduce hyperactive behaviors with additional support and redirection. Client is seen dealing with stressors and coping appropriately. Client utilized conflict resolution skills in school by problem solving on his own and compromising with his peers. (EOD) Client reviewed goals and objectives. Client admitted he needs improvement and plans to practice skills and strategies at home in order to stop complaining about doing work in school. Client was able to eliminate unwanted behaviors and implement new strengths. Client benefited from positive reinforcement. Client engaged in self-reflection and role-playing activities to correct his mistakes. Client demonstrates excellent conduct at this time while displaying responsible behavior, ending the day on a good note.