11/1/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed walking into class and hanging up his book bag and coat. Client prepared for the assembly by lining up with his class and transitioning to the cafeteria. Client was sent out of the reading assembly, due to not being able to stay seated and be quiet with the rest of his class. Client fell asleep by the front of the school. Client did not participate in morning activities. Teacher reported client can utilize this as his first break and should be ready to begin his day by time lunch arrives. (PM) Client was observed in lunch displaying appropriate social behaviors with peers. Client was polite to staff and exhibited good manners by saying "thank you" and "excuse me". Client expressed positive emotions. Client was able to eat his lunch without getting up out of his seat and causing disruption. Client was monitored and supported for his cooperation and following lunch rules. Client walked to his session area safely and smoothly. Client greeted counselor. Client prepared for psychoeducational. Client was seen conversing with peers without intiating conflict. Client exhibited appropriate voice volume by using his inside voice. Client interacted well during group and demonstrated good team work skills by sharing and taking turns. Client was observed exhibiting positive behaviors. Client appeared to be in a relaxed mood, as evidenced by his demeanor and calm facial expressions. Client walked back to class. Client was praised for not running down the hallway when returning to class. Client smiled and went straight to his desk. (EOD) Client was seen at his desk on task and following teacher's directives. Client was observed fully participating in classroom activities. Client was supportive of his peers by listening and paying attention when it was not his turn to talk. Client raised his hands to contribute to group discussion. Client was observed playing fairly and interacting with peers without display of negative or impulsive behaviors. Client appeared to be focused on the lesson being taught by his teacher. Client showed interest in his school subjects. Client did not require redirection going into dismissal. Teacher reported client was well behaved during each activity. Teacher stated client stayed in his seat and completed his work. Client demonstrates a good attitude despite stressful environment and continues to follow directions even when his classmates were being redirected by the teacher. Client was given appropriate recognition before leaving school. Client met all objectives. (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.