When starting out in private practice, you’ll face several important financial decisions, including what fees you’ll set for therapy services. Deciding how much to charge per session may take some time and consideration. If you work with both individuals and couples or families, you may have one rate for individual therapy and another rate when you work with more than one person at a time.
Whatever rate you set, it’s important to make sure it’s affordable but not so low it undercuts other providers. You also need to charge enough per session to allow you to cover your operational costs and still earn a living. But you’re probably also aware that not everyone who wants to seek treatment can afford to pay for it. This awareness may prompt you to consider a sliding fee scale.
Sliding scale therapy refers to treatment priced by each person’s income and dependents. This fee structure exists to help make therapy more affordable for people living at a lower income level.
A sliding fee scale may be ideal for clients who pay in cash, often because they don’t have health insurance. If you accept insurance in your private practice, a sliding scale may be harder to implement. You typically can’t charge people with insurance on a sliding scale, since this could result in you receiving a higher or lower payment than you’re receiving from the insurance company. Doing so could put you at risk for insurance fraud or other legal issues, whether you do so in ignorance or with good intentions. In most cases, the contract you have with an insurance company will prohibit you from changing a client’s copayment in any way.
If you’re not comfortable with math, you may feel somewhat daunted by the process of establishing a working scale. You can often find clear, easy-to-follow worksheets online, but these tips can help you get started:
One important consideration involved with sliding fee scales is the possibility of price-gouging. While this certainly may not be your intention, a sliding fee scale, by its very nature, charges people with higher incomes higher fees for therapy. Arguably, people with higher incomes can often afford to pay more for therapy, but you may find it helpful to create a worksheet explaining how you set your scale. Have this ready in case your clients have questions about the session price.
If you’re not sure whether your sliding fee scale meets ethical guidelines, it doesn’t hurt to talk to an attorney or other legal expert.
If you choose to offer a sliding fee scale, it’s important to determine a fee with each client at the beginning of therapy. Some therapists choose to ask for proof of income, while others trust clients to share truthful information on their finances.
Once you’ve determined a fee with your client, create a document and sign it together. Since life circumstances, including employment or income, may change over the course of therapy, it might be necessary for you to revisit this fee at some point. Keep your client’s financial information worksheet in their file so you can refer back to it if needed and make any necessary changes.
Many therapists and other health care organizations use annual United States federal poverty guidelines to set sliding scale fees. These guidelines can be helpful tools for your practice since they’re standardized throughout the country and based on income and dependents. For example, an individual may make $20,000 a year but have 1 dependent, so they would make slightly under 125% of the poverty threshold. You may put this person on the lower end of the scale, but not as low as someone who is under the poverty line.
According to the American Counseling Association’s ethics code, you may be able to adjust your session fees at your discretion if they would create financial hardship for a person in therapy. Keep this provision in mind you’re concerned about the possibility of clients who, due to their annual income, have a higher session fee than they feel comfortable paying,
You may have concerns about offering a sliding fee scale. Remember, you’re under no obligation to offer this fee structure. While some therapists use sliding scales to make therapy more accessible, you can help make therapy more affordable in a number of ways.
Here are some possible options:
You can reserve a few sessions for pay-what-you-can clients who choose their own therapy fees. You might suggest a minimum payment of $10 or $20, for example, or leave it entirely up to the client. You could also consider offering a limited number of pro-bono (free) sessions.
This may not work long-term or for all clients, but if you’re working with someone who has a temporary financial setback, you might consider allowing them to continue in therapy while paying only a small portion of their session fee each week. You can draw up a payment plan that allows them to pay the rest of the balance when they’re more financially stable.
You may be surprised to learn that bartering is considered an acceptable form of payment in certain circumstances. Bartering must not create a dual relationship, and it must not put the success of therapy in jeopardy. To create a fair trade, weigh the value of a session against the value of the goods or services exchanged.
Hiring your client to babysit your children in exchange for therapy may create a dual relationship. But asking a web developer client to exchange an hour of work on your website for each hour of therapy may be acceptable—unless that person is in therapy for burnout at work. In that case, the exchange could be harmful and unethical.
If you would like to know more about growing your private practice, consider joining GoodTherapy for access to continuing education courses, webinars, and more.
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