Arianne JNae Broadnax, LRT/CTRS

5550 Sturmer Park Circle Winston-Salem, NC 27105 Phone: (336)-515-0617

Professional Disclosure Statement
I am pleased and honored to have the opportunity to work with you. The following information is
designed to inform you about my background and the nature of our professional relationship. We will
discuss any questions you may have regarding this information and any others you may have relative to
beginning our work together.
My Qualifications: I received a Masters of Science in Clinical Mental Health Counseling from Wake
Forest University in August 2016. I am working toward pursuing professional licensure as LPCA. I will
operate under the supervision as a Licensed Professional Counselor Associate in North Carolina post
receipt of LPCA credentialing.
Professional Background: Previous counseling experiences include two clinical mental health
internships. Internships were completed at Old Vineyard Behavioral Health Services in the Partial
Hospitalization Program working with adults and Community Intervention & Educational Services,
Outpatient Therapy working with children and teens. These experiences created opportunities to learn
about Trauma Focused CBT, EMDR, Play Therapy, DBT and Substance Abuse Counseling. Prior
mental health experience has been gained over the course of several years working at Amos Cottage as a
Recreational Therapist. I have worked in early intervention behavioral health services at a Day treatment
program for young children ages 3-7 for the past 9 years. I have also gained experience working with
severe, persistent mental illness while serving in the same role of a Recreational Therapist at Broughton
Hospital providing group therapy to patients with severe /persistent mentally ill adults. My tenure as a
Recreational Therapist has provided the opportunity to develop and engage in basic helping skills,
providing therapeutic services, such as assessment, group facilitation, treatment planning and working as
a part of multidisciplinary teams. My experiences have afforded me the privilege of working with many
diverse groups gaining skills in group facilitation, using recreation & leisure based interventions as my
tool in promoting mental health stability. I strongly desire to incorporate my skills gained in Recreation
Therapy with my counseling degree as I learn new and exciting counseling approaches and
interventions. It is my desire to pursue specialty certifications and training subsequent to obtaining my
professional licensure pertaining to Substance abuse, CBT /Trauma Focused CBT, DBT and play
therapy to enhance my counseling skills. I am also licensed by the State of NCBRTL- (North Carolina
Board of Recreational Therapy Licensure #1311) as well as nationally certified through NCTRC
(National Council for Therapeutic Recreation Certification #48272).
Theoretical Approach/Counseling Process: I believe the counseling process is a collaboration between
client and therapist. My current theoretical orientation operates on the premise of integrating Cognitive
Behavioral Therapy, Person Centered therapy, & Strengths based- Solution focused approaches with
Recreational Therapy. Cognitive Behavioral Therapy places emphasis on problem solving by changing
patterns of thinking or behavior that are beneath the problem in order to change feelings. PersonCentered Therapy views each person as unique, valued and worthy of unconditional acceptance.
Solution Focused Therapy focuses on addressing personal goals by exploring the history and origin of

problem(s), emphasizing focus on the present and future, focusing on the past only as deemed necessary
for gaining an understanding of the client's concerns. I also value incorporating components of using
recreation and leisure interest as vital components to developing healthy coping skills and maintaining
lifelong mental stability. My goal is to provide an atmosphere of safety and trust in order for you to
discuss things openly and honestly. We will explore your initial concerns, develop goals and discover
strengths and resources together as we work toward your goals. It is imperative that all patients and their
families are aware of the professional nature of our relationship with contact being limited to the
sessions conducted with you.
Risks: There are potential risks associated with the counseling process. As well explore areas of
concern, you may find feelings of sadness, frustration, anger, grief or anxiety emerge. Please know that
this is a natural part of the therapy process.
Session Fees and Length of Service: Therapy sessions are typically 45-50 minutes and depending on
the nature of the presenting problem, sessions are generally scheduled once weekly. It is difficult to
predict how many sessions will be needed, however after the clinical interview/intake sessions, I will be
better able to determine a probable number of sessions. Appointments may be scheduled, rescheduled or
cancelled by phone Monday -Friday. Failure to give notice for any appointments not cancelled 24 hours
in advance will result in a charge for the time reserved for you. Fees for each session are collected at the
end of the session and before subsequent appointments are scheduled. Fees are charged for each type of
session are: $80.00 per hour (45-50-minute session). Acceptable methods of payment accepted (cash,
check, credit card, etc.) and information about billing and insurance reimbursement.
Use of Diagnosis Some health insurance companies will reimburse clients for counseling services and
some will not. In addition, most will require that a diagnosis of a mental-health condition and indicate
that you must have an illness before they will agree to reimburse you. Some conditions for which
people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate in
your case, I will inform you of the diagnosis before we submit the diagnosis to the health insurance
company. Any diagnosis made will become part of your permanent insurance records.
Referrals and Complaints: I abide by the ACA Code of Ethics
(http://www.counseling.org/Resources/aca-code-of-ethics.pdf. If at any point you are dissatisfied with
my service, please feel free to inform me directly. If I am unable to resolve your concerns, I will provide
you with referrals to other counselors in the local community who may be of better service to you. You
may file a complaint to:
North Carolina Board of Licensed Professional Counselors
P.O. Box 77819 Greensboro, NC 27417.
Phone: 844-622-3572 or 336-217-6007; Fax: 336-217-9450
E-mail: Complaints@ncblpc.org.
Confidentiality: All information that is shared with me during sessions and information obtained
outside of sessions is strictly confidential. All of our communication becomes part of the clinical record,
which is accessible to you upon request. I will keep confidential anything you disclose as part of our
counseling relationship, with the following exceptions: (a) you direct me in writing (signed release
form) to disclose information to someone else, (b) it is determined you are a danger to yourself or others

(including child or elder abuse), or (c) I am ordered by a court to disclose information. It is also
imperative that you know that I am a mandated reporter and required by law to
Acceptance of Terms: We, the undersigned, have read, discussed together and fully understand and
agree to the contents of this disclosure statement. By signing below (a photocopy will be provided to
you for your records) you are indicating that you have read and understood this statement and any
questions you had about this have been answered to your satisfaction.
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Minors)
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JNae Broadnax, LRT /CTRS

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