What is sliding scale, and is it right for me as a therapist?

In your own practice, you may be curious to learn more about how to provide sliding scale rates, or if it is even appropriate for your practice.  Therapy is a powerful tool, but it can also be financially inaccessible for many people.  A sliding scale rate is a fee mutually agreed upon by the therapist and the client when the client is experiencing financial barriers to paying the full fee.

Deciding whether to offer sliding scale rates, and how many sliding scale clients to accept, is entirely up to you. It is important to balance accessibility with sustainability. As mental health clinicians, we carry significant professional expenses, including licensure fees, continuing education, office costs, consultation, and other overhead fees. At the same time, the ACA Code of Ethics encourages us to make reasonable efforts to provide services to the public, whether through sliding scale fees, pro bono work, or community outreach.

Determining a Sliding Scale Rate

There are several ways to determine an appropriate sliding scale rate and navigate these conversations with prospective clients. Below are a few commonly used approaches:

Percentage of Income Model: One option is charging 2% of your monthly income.  If you made $2,400 a month (2,400 x .02), 2% would be $48 per session.

Anti-Oppressive Model: Kenya Crawford, a licensed therapist in New York, has created an anti-oppressive rate structure grounded in community equity and wealth distribution.  This model uses guided questions to collaboratively determine a fair rate. 

Hourly Rate Model: Dr. Raquel Martin, a psychologist in Tennessee, sets the rate with clients based on how much the client makes for an hour of work.

Collaborative Conversation Model: Some clinicians prefer an open discussion with the client.  Telling the client your hourly rate and deciding together what is feasible is another option that can have some flexibility.  If you use this approach, be sure to have a minimum number that you are willing to accept to maintain transparency, boundaries, and professionalism.

Session Frequency and Time Considerations: How often you are seeing the client may be another consideration in setting the rate.  Some clinicians will give a lower rate for weekly sessions and a higher rate for biweekly sessions, reflecting the clinical continuity and treatment consistency.  You can also consider making your sliding scale slots limited to daytime or harder-to-fill timeslots.

IMPORTANT: If you accept the insurance of a client requesting a sliding scale, review your contracts carefully. You will want to have some sort of “Opt-Out” form for the client to sign, stating that you are not liable and not obligated to reimburse sessions where they have chosen to opt out of billing their insurance.

Determining Eligibility for Sliding Scale

Another important question to consider is eligibility for sliding scale, and how many sliding scale slots you wish to have in your practice.  Below are some commonly used approaches when it comes to eligibility:

Proof of Client Income: This method requests pay stubs in order to see if a potential client is eligible for sliding scale.  This information may be evaluated alongside state poverty guidelines, number of dependents, and additional financial responsibilities such as medical expenses. 

Collaborative Conversation if Eligibility is Appropriate: A more open-ended approach is to choose not to request documentation, which is also a valid approach. Instead, they engage in a transparent conversation about what the client can afford. If you take this route, it can be helpful to ask structured questions to assess financial strain, such as:

-Do you live alone or with others?

-Do you have access to family or financial support?

-What ongoing expenses do you have (ex: medication, student loans, childcare)?

Number of Sliding Scale Slots:  It is also important to determine how many sliding scale slots you can realistically offer. Reviewing your budget and honoring your own financial needs is essential for long-term sustainability as both a clinician and a human.

IMPORTANT: When you do agree to a sliding scale rate with a potential client, be sure to document the clinical and ethical rationale for offering the reduced fee, and the process used to determine the rate.

Final Thoughts and Considerations

It is strongly recommended to get consultation to process your own beliefs related to money, wealth, financial conversations, and any possible countertransference that may arise in a sliding scale relationship.  These reflections will prepare you to navigate these conversations with clients.  This is particularly important when increasing rates annually, or when a client’s financial circumstances change.

In the event you are unable to provide services to a client requesting a sliding scale, be sure to provide them referral options.  Open Path Psychotherapy Collective is a great resource that offers low-fee clinicians to clients.  

Offering sliding scale slots can feel rewarding in the work that you do both clinically and ethically.  However, maintaining healthy and transparent boundaries are crucial in providing this work and in determining what is sustainable for your business.  Doing more research about sliding scale and your own values as a clinician can help decide if this is right for you.