Sliding Scale Fees: An 8-Step Therapy Private Practice Guide

Setting sliding scale fees can be a great way to make your therapy services accessible to clients who would not otherwise be able to afford them. At the same time, having a sliding scale policy that is vague, unstructured, or out of balance can lead to misunderstandings, financial difficulties, and even impact the course of treatment.  

Taking ethics, fairness, and finances into consideration, does offering sliding scale make sense for your business model and practice philosophy? How will adding sliding scale options impact your bottom line budget? How might it affect your risk of burnout? Consider these and other questions included below when evaluating whether offering a sliding scale is a good fit for your practice, and how to develop a sliding scale that works for you and your clients.

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What is a sliding scale fee?

A sliding scale is a range of therapy session fees that a therapist may offer, based on a client’s ability to pay. A therapist may offer a client lower fees than their typical sessions relative to a client's income or financial situation, so clients may afford  sessions and access mental health care.

This lowered fee may be offered at the beginning of treatment when a client and therapist first start to work together, or it may be offered mid-treatment if the client's financial situation significantly changes.

Regardless of when a lowered fee is offered, it can help private practice therapists to have a clear sliding scale system so that if a client asks for a lowered fee, you know exactly what you can and are willing to offer in your practice.

Should I offer a sliding scale fee?

You may feel pressure to implement a sliding scale system from colleagues and clients alike. This pressure is twofold: it can feel stressful when clients ask why you don’t offer sliding scale fees, and it’s also difficult to reduce the monetary value placed on your services.

It may help to remember that therapists aren't bound to offer sliding scale fees for their services. Most therapists’ professional code of ethics require them to support their communities, but there are many ways to do this, and it doesn’t have to be through offering lower session rates; you could offer payment plans instead, or do pro bono work separately from private practice.

If you decide the best way for your practice to give back to the community is by offering a sliding scale, you don't have to do so when you're first starting out. It's often best to wait for your practice to reach a stable client load, so that you won’t be pressed to take on more work to reach your target income. At all times, keep in mind that you need to maintain your own wellbeing as you support your clients, and feeling financially secure is a key part of that.

Reasons to offer a sliding scale

There are many reasons you may choose to offer clients sliding scale fees. Here are a few to consider:

Reasons not to offer a sliding scale

There are also a few reasons why sliding scale fees might not be ideal for your practice. If these apply to you, it may be worth reconsidering a sliding scale structure:

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Alternatives to sliding scale fees

There are many ways to accomplish the goal of offering lower-cost therapy and making mental health care accessible for all. Here are a few alternatives or adjustments to consider about as you think through sliding scale for your practice:

How to set a sliding scale policy

Ready to implement a sliding scale system at your practice? A practice fee setting calculator is a great place to start! If your practice is already up and running, there may be some mental gymnastics in order to balance your session numbers, costs, and new, incoming referrals. If you’re just starting your practice, you might consider including sliding scale sessions into your business model from the outset. Here's how to get started, no matter where you're at in your private practice:

1. Consider the number of clients you’ll take on through your sliding scale system

How many total clients will fit into your ideal caseload? Consider how hours you'd ideally work each week, allowing yourself enough time to take care of yourself and stave off burnout, but still make a profit.

How many of your caseload will be sliding scale clients? Generally, practice recommendations include that sliding scale clients should be no more than 20% of your census. So, if you're taking on a caseload of 20 clients per week, around 4 of those people could potentially be on a sliding scale.

2. Determine your minimum session fee

The minimum session fee is the lowest amount that you’ll charge per session for those clients who demonstrate a very limited budget. Once you have this number, you can build upon it as clients’ budgets increase. Your minimum session fee is completely up to you, but don’t sell yourself short! Especially if you have a lot of experience or additional certifications, make sure that the minimum fee is something you're comfortable with personally and from a business perspective.

Making sure that the session fees across the sliding scale are fair will not only help you maintain your professional ethics shows your clients that you take your work seriously. By having a straightforward system based on financial need, you demonstrate that you're business savvy while also willing to be flexible in the name of helping people. To create your system, build a table that includes income, number of dependents, monthly costs, and other financial factors that determine need.

3. Consider the time limit for your sliding scale policy

Will you have a set start and end date for each sliding scale client, or a particular number of sessions that people can access via sliding scale? If your goal is to offer therapy services for a wider population, limiting the number of sessions a client receives means that you’ll be able to see more people — and support more people’s mental health in the community.

4. Make sure that your sliding scale policy abides by your other practice contracts

Double check that you don’t have agreements stating that you cannot charge different session fees. Often, insurance companies include clauses in contracts that say that you cannot charge lower fees for clients who do not use their insurance or do not have insurance. By covering your bases, you’ll avoid any potential legal issues in the future.

How to discuss sliding scale with clients

Now that you’re set with your sliding scale system, it’s time to speak with clients about it. This is a conversation that often comes up with prospective clients (as well as current clients), so being prepared will make a potentially uncomfortable conversation easier.

5. Set gentle (but firm) boundaries with clients

It’s important to have clear boundaries on what you’re willing to do and what you are not willing to do when it comes to session fees.

Having a set policy to refer to makes it easier in the middle of the conversation to set these boundaries — especially if it’s on your website or posted in your office.

By being intentional about your sliding scale policy ahead of time, you won’t lose sight of what’s acceptable for you and your practice.

6. Remain calm, confident, and compassionate whenever discussing your fees

When the session cost comes up in an introductory call, calmly and confidently disclose your sliding scale policy. Clients will appreciate that you are leading with compassion, and not leaving anything up to interpretation. Having a loose script at the ready may help (more on that below!).

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7. Practice how you'll address different client needs, responses, and questions

Here are a few examples of ways to talk about your session costs while maintaining your boundaries:

If a client asks for sliding scale and you are NOT currently offering it:

If a client asks for sliding scale and you ARE currently offering it:

If you are setting a limit on the number of sessions you offer via sliding scale:

8. Practice empathy and reflective listening during money talks

Remember that your therapeutic skills stretch outside of the traditional session setting – your innate compassion and ability to empathize with clients in need will come in handy when navigating these hard conversations. Reflective listening may ease the tension of the discussion, especially if the news isn’t what the client wants to hear.

Though these conversations can be nerve-racking, talking slowly and clearly reduces the chance of a misunderstanding.

Of course, once a client starts on a sliding scale fee for their sessions, it’s time to focus solely on their therapeutic care and not so much on the details of the arrangement. By bringing up their reduced fee or your practice’s limitations with clients like them, you may damage the relationship and go against the goal of sliding scale in the first place.

Sliding scale systems are great when your practice is ready to assist a larger population. They’re incredibly helpful for many, but should only be offered when you are in a financial position where it makes sense.

Whether you decide to implement a sliding scale or not, take a deep breath — you’re doing the best you can for your practice. You’re in the business of helping others. While that generally means that you find ways to support as many people as possible, there’s nothing wrong with looking out for the wellbeing of your business (and yourself!). By having clear policies and offering alternatives to clients, you’re making the right decision, no matter what that decision is.

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