4/19/2023 EnchantaVaughn Approved (AM) Upon arrival, client presented a positive attitude towards peers and teachers as he walked through the hallways to get to class. As the client settled into class, he was seen putting away his book bag and waiting for instructions. Client was in a good mood while preparing for his day. Client began morning assignment without interrupting others who were trying to learn and this behavior was monitored and supported. Teacher reported that client has been coping well although he’s a part of a stressful environment. Client exhibited excellent classroom management by sitting quietly and giving his undivided attention. Client maintains an uplifted spirit despite the distractions in his class. Client is very attentive to his work and is encouraged to keep up the good work. Client demonstrates good teamwork skills in academic setting. Client is seen smiling and laughing with his peers and complying to classroom rules. As the client transitioned into lunch, he was observed lining up correctly and respecting other student’s personal space. (PM) Client was observed during lunch displaying good behaviors. Client had appropriate interaction with his peers. Client was having appropriate conversation. Client expressed positive thoughts. Client was respectful of staff and peers. Client walked over to QMHP to begin psycho social activity. Client exhibited full participation in group setting. Client was observed in his seat and being a good listener. Client was monitored following directions and being respectful to QMHP. Client displayed age appropriate behaviors, working well with others and being a team player. Client was observed keeping his hands and feet to himself. Client is supported with asking for permission to go to the bathroom and does so without getting off track. Client had a hard time returning back to class after sessin was complete. Client refused after several prompts and had to be redirected back on task. Client has had extreme difficulty verbalizing his thoughts and feelings to QMHP especially when he is upset and frustrated. The client was taught alternative ways of expressing negative emotions (e.g. writing, drawing, physical activity, or talking to a friend) but the client’s psychotic thinking persists, despite the use of coping skills and other interventions, and he was provided with additional support in this area. Client walked slowly to class because he did not want to go. Client was educated that being in class is just as important as him coming to school everyday. Client communicated non verbal cues that he was feeling insecure and needed a moment to regroup. (EOD) Client was not in a happy mood when classtime started and teacher reported client had a tough time transitioning into the pm activities provided to the class. Client sat at his desk for a while doing nothing. Client exhibits a poor attitude when given support and encouragment from QMHP. As the client was provided with a calm environment and reassurance that he would be cared for, his level of agitation has decreased. Client was observed sharing and being fair to others in class. Client remained in his seat and was able to refocus his attention to more favorable acts of kindness and being influenced by peers who were doing really good in class. Client was supported for getting himself together and turning his day around. Client appeared to be enjoying himself around others and listening to his teacher while she taught the final lesson of the day. Client was seen being polite and respectful towards his classmates that were sitting next to him and contributing to the classroom activity. Client displayed appropriate behaviors at this time while packing up to prepare for announcements and dismissal. Client met objectives 1 and 3, but needs to work on objective 2 due to failing to demonstrate appropriate coping skills while transitioning back into class. (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 inquired about 3-day weekend activities, asking what was exciting about your weekend. QMHP inquired about morning routine and how client was feeling. 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 about last week's behaviors, the good and bad. 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 offered help. QMHP encouraged client to continue having a good day. (EOD) QMHP monitored for acquisition of objectives. QMHP redirected client negative behaviors. QMHP encouraged client to stay in class and comply to rules and directives. QMHP encouraged client to be the example. QMHP encouraged client not to follow others that he see are doing wrong. QMHP intervened to assist in explaining behaviors to client. QMHP reflected with client on his day, both happy and frustrating experiences. QMHP encouraged client that tomorrow is a new day. QMHP processed client feelings. QMHP engaged in active listening. QMHP assisted client with recognizing his own personal strengths and how to apply them to reach his goals and objectives. (AM) Client greeted QMHP by saying good morning. Client reflected on his weekend activities. Client said he woke up feeling good and was ready to have a good day. Client expressed positive thoughts about himself. Client stated he didn't need help with anything at the moment but would tell an adult if he needs help. Client communicated by nodding and exhibiting good eye contact. 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. (PM) Client said thank you and continued to do what he was told. Client said he was going to have a good day and decided to practice yoga poses with group member before returning to class. 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 was displaying respectful, non aggressive behaviors in lunch. Objectives were being met at this time, dispite stressful environment. (EOD) Client avoided distractions in social setting, while utilizing anger management skills. Client seem to have a big influence on his peers. Client displays leadership skills by helping others and being a good citizen in school. Client acknowledged interventions and verbalized clear understanding. Client engaged in reflective thinking. Client communicated the do's and don'ts. Client was in a pleasant mood after feedback was given. Client was seen having a good evening. Client was able to identify the role he plays in each situation and continues to comply with authority rules and regulations. Client remembered to apply himself and utilize his strengths to focus on meeting his goals and objectives.