4/10/2023 EnchantaVaughn Approved (AM) Upon arrival, client was observed entering the school building in a jovial spirit, as evidenced by his happy facial expressions and smile. Client greeted QMHP and communicated he was in a good mood and felt refreshed. Client is observed listening and following directions in class. Client is cooperative and attentive while teacher was reviewing lesson. Client demonstrates excellent team work skills by sharing and taking turns with his peers. Client displays appropriate social skills by working together and helping others. Client is supported for his contribution and having a good start to his day. (PM) Client was observed in lunch line and being respectful and polite to staff by saying please and thank you. Client sits correctly in his seat and held appropriate conversation with peers. Client was seen cleaning up his trash and asking for permission to see his counselor. Client was full of energy and excitement. Client was happy to see his group members, as evidenced by him laughing and playing safely. Client displayed good social interaction. Client demonstrated good team work skills. Client demonstrated good manners to staff by being courteous and respectful (e.g. holding the door for others, waiting his turn, and saying please and thank you). Client was monitored in his seat and conversing politely with his peers. Client joined session in a calm manner, demonstrating self-control in the social environment. Client was able to implement focusing strategies as he watched the visual aid. Client displayed appropriate social behaviors until it was time to go to the pageant rehearsal. (EOD) The client was reinforced regarding his ability to cope with negative feelings about self without feeling threatened. Client was observed following directions and ignoring distractions. Client participated in group exercise and was observant to his surroundings (e.g. recognizing when to walk away or mind his business). Teacher reports giving client support and encouragement to enhance his self-esteem. Client was educated with mental health skill building and given the resources he needs to practice the appropriate behaviors. As time progressed, the client has demonstrated a cooperative attitude while being supportive of others. Client followed his instructions and stayed on task until dismissal. Client was able to achieve goals and objectives. (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.