How to Determine Sliding Scale Fees
Updated March 2024
A sliding scale fee for therapy is offering a different price based on the client’s ability to pay. For example, a counselor might offer a sliding scale to provide increased financial accessibility to mental health care by lowering the fee rate to better accommodate a client who has a lower income or a more precarious financial situation. While sliding scales aren’t uncommon or unethical, they do require some forethought and a clinician’s ability to adhere to financial boundaries.
In this post, I’ll cover who should offer a sliding scale, different ways to create sliding scale guidelines, and provide alternatives to a sliding scale.
Who Should Offer a Sliding Scale
Anyone who is in a service-based industry could offer a sliding scale. Offering a sliding scale can feel like an important measure of accessibility for some clinicians or therapists. For that clinician, they have to decide what their sliding scale will look like, how many sliding scale spaces they’ll offer, and the guidelines for new and current clients.
However, just because it’s allowed doesn’t mean it’s advisable. Personally, I don’t offer a sliding scale as I chose to give back to my community and causes that matter to me outside of my business. My opinion is that too many women, global majority/racial minorities, working-class/poor people, and other marginalized groups of people are often “used to” working more for less and haven’t stopped to consider why they want to offer a sliding scale.
If a sliding scale feels important to you, I invite you first to have your private practice finances steady and sustainable before opening up sliding scale spaces. As a coach and consultant for private practice therapists, I’ve heard far too many therapists implement a sliding scale first, as their way to “fill” their practices. They tell themselves that once they have a full caseload, then they’ll raise their fee. Sadly, this approach usually backfires because they can’t afford to see so many clients paying so little, and they find themselves overwhelmed with low-paying clients.
Sliding Scale Guidelines
Determining sliding scale fees can be tricky. With the disclaimer out of the way that not all clinicians have to use a sliding scale, there are some potential guidelines to consider. When you are considering the reasons behind offering a sliding scale, one of the most common reasons is that a potential client may not be able to afford your full fee due to their financial situation. Here are five different ways of structuring a sliding scale.
1. Income-Based Sliding Scale
The most common sliding scale model I’ve seen is an income-based sliding scale. This guideline takes a client’s income and compares it to the current federal poverty guidelines. This usually looks like paying the full fee if a person is 3x or higher the federal poverty guidelines, paying a mid-range fee if a person is 2x the guidelines, and a nominal fee if at the poverty guidelines.
2. Marginalized-Identity Sliding Scale
Income and personal finances are a popular way to implement a sliding scale, but you can also extend a sliding scale based on a client’s identity. As always, check with your ethics board and lawyer to ensure you aren’t violating any of your professional code of ethics, but this approach can feel good for some therapists. This might look like extending a sliding scale to first-generation college students, people undergoing gender-affirming care, or religious minorities.
3. Social-Justice Based Sliding Scale
Alexis J. Cunningfolk says instead of deciding for clients what they can afford based on their income, extending to potential clients a chart and letting them decide where they fit in. They say that creating a sliding scale in this way “thrives on trust” while allowing people to decide where on the pricing and fee spectrum they can comfortably afford to pay. Using this model, you present clients with the above “Green Bottle” graphic, and ask them to self-assign their fee based on where they land. For example, if your fees were $100, $125, and $150, a client would select $125 if they fit into the middle category of being able to meet their financial needs even if occasionally they stress about their finances.
4. Pay What You Can Sliding Scale
Similar to the model by Cunningfolk, a pay-what-you-can sliding scale again puts the client in the driver’s seat. This looks like telling a potential client what you usually charge, and asking them what they are able to pay compared to that fee. The hope is that most clients will be able to afford your hourly rate, and for those that name a different price, the clinician is able to honor their lower requested rate.
5. Assigned Sliding Scale
An assigned sliding scale model is where you determine the revenue you need to generate and create assigned spaces to ensure you are compensated fairly for your services. This looks like having several spaces at the average rate you need to earn, and a few spaces above and below that rate. For example, if you needed to average $150 for your services, you’d offer 3 spaces at $100, 5 spaces at $150, and 3 spaces at $200. When extending this model to your clients, you can combine it with the above “green bottle” graphic. Alternativley, you can say something like, “It’s important to me that when clients are able to afford my higher fee, they do so and know they are supporting access to mental healthcare services to those who may have a hard time accessing these services otherwise.” Being transparent about why you offer an assigned sliding scale can help your clients join with you in a social-justice-minded private practice.
Downsides of a Sliding Scale
The downsides of offering a sliding scale in a service-based business are that many people don’t know if they, as business owners, can afford to offer discounted rates en masse. Other barriers or downsides of implementing a sliding scale include:
Potentially overworking to make up for lost revenue.
Adhering to boundaries if/when a client’s financial or life circumstances improve.
The potential discomfort of the business owner or client using the sliding scale.
I’ve spoken with clinicians who quietly tell me they resent the clients who pay them less. If implementing a sliding fee scale in your therapy business will impact your therapeutic relationship with your clients, you should not use one.
Alternatives to a Sliding Scale in a Therapy Business
Money is only one domain of accessibility. There are so many other ways to assess for accessibility that don’t include your fee. Instead of offering a sliding scale as a therapist in private practice, there are other alternatives to accessibility that you can consider.
Pay-it-Forward
The pay-it-forward model is one in which you invite clients who are able to comfortably afford your services the option to pay a little bit more. Those additional monies will go directly toward supporting the fee of someone who might have used or qualified for a traditional sliding scale. Think of this as a scholarship model, but for your business. Again, check with your profession’s ethics rules to see if this is a viable option for your practice.
Flexible Scheduling
If clinically appropriate, you can offer flexible scheduling options. This might mean seeing a client every-other-week instead of weekly but maintaining your full fee. Of course, this might not work in a therapeutic setting where a client needs more frequent visits, but it could be an option for a client not in crisis.
Teletherapy
The option of teletherapy can be a great bonus for folks who live in rural areas far from therapists' offices, for folks who are disabled and have difficulty with mobility, and for neurodiverse folks who may struggle with time management. It’s also a great option for stay-at-home parents who may have difficulty finding childcare to attend therapy.
On the route of public transportation
Having an office in an easy-to-access
First floor or elevator access
Not having to climb stairs or hunt for a way to get into the office
Easy access to parking
The ability to park near your office or to have dedicated free parking
Nontraditional Hour Offerings
Many clinicians, myself included, work more traditional “bankers hours.” Offering appointment times outside of those hours is a way to be accessible.
Visibility as Accessibility
I can harp on this until the cows come home, but showing up as your full, messy, and authentic self is a measure of accessibility. Especially if you occupy any marginalized identities (autistic, racial global majority/marginalized race, religious minority, LGBTQIA, chronic illness, etc.) being yourself can provide access to others who share an identity or identity with you.
Thinking Beyond 1:1 Work
Therapy groups–Working with a small group to decrease each participants’ out of pocket cost while ensuring your hourly fee is met
Public speaking–Finding or agreeing to paid speaking engagements
Psychoeducation or coping skills workshops–Presenting at schools, corporations, or hospitals on a topic as a way to increase access and get paid for your knowledge and expertise.
Furry Friends
Allowing pets into the therapy session (pending allergies, of course) regardless of their “official” emotional support or registered therapy status.
Final Thoughts On Therapy Sliding Scales
At the end of the day, the business owner has to decide if, and why, they want to offer a sliding scale. Once they’ve made that decision, they have to make sure that their business can be financially sustainable by implementing a sliding scale. This might look like having a limited number of sliding scale spaces, only offering a sliding scale after their business is in the black (aka making profit regularly), or implementing a version of the traditional sliding scale that better aligns with their values and the values of their practice.
Sliding Scale Help
If you are a therapist or allied care provider in private practice and are struggling with creating a fee structure that works for you, I can help! Sometimes when we struggle, we really need clarity and guidance on what we need to focus on in our practice, learning how to market our practices, or something else sustainably. I’ve got a suite of mini-courses just for private practice therapists here: