True or False? Legally, you have to offer sliding scale to clients

We received a reader response in our inbox the other day after they read our recommendation that therapists in private practice should "Slide for no more than 20% of your caseload, and make sure your fair fee for the other 80% of clients allows you to meet the needs for health care, benefits, time-of, etc." 

Might want to check how ethical this is. My understanding is that BBS and or CAMFT ethically require a clinician to extend the same sliding scale to ALL clients...

Great question! We want to make sure we (and you) are always doing what is right and ethical! I love it when people question and really explore. While each state may have different ethical and legal obligations, we can definitely talk about the state of California today (which is where this question came from): 

#1. There is no ethical obligation to offer a sliding scale in your private practice at all. 

The code of ethics for MFTs in California states:  

"7.5 PRO BONO SERVICES: Marriage and family therapists are encouraged to participate in activities that contribute to a better community and society, including devoting a portion of their professional activity to services for which there is little or no financial return."

Notice that the ethics report "encouraged" not required, and that we should devote a "portion" of professional activities for things that give us little financial return. Examples could include:  

  • Volunteering to provide direct services

  • Speaking for free to community organizations

  • Free or low-cost supervision for pre-licensed folks

  • Volunteering on a local non-profit board or professional organization

  • And yes, low-cost or no-cost services provided to clients.

There are many ways for you to give back and be awesome. You could have no sliding scale fee slots in your practice and be ethical (in California- I haven't checked every states code of ethics). Or, you can have a portion of your weekly session slots be sliding scale. 

In CPH Insurance's avoiding liability bulletin in April of 2006, they say this about sliding scale fees for private practices: 

"My view is that a ”sliding fee scale” is unnecessary, unwise and problematic. Most sliding fee scales used by nonprofits and other entities base the fee on the financial condition of the patient. In order to properly implement such a policy, entities must ask for certain information and perhaps supporting documentation, like tax returns. Most private practitioners do not want to get into that kind of detail in their practices. Psychotherapists usually establish fees that they are comfortable charging and stay with those fees until they decide to raise their fees. Physicians and other practitioners likewise establish a “usual and customary fee” and typically do not change their fee for different patients. If the patient can’t afford the fee, he or she can be referred elsewhere."

In fact, even in the social workers code of ethics, it gives the option to refer the client out to a sliding scale clinic if they can no longer afford services. 

The thing that you legally can't do is "slide up" or create fees willy nilly. Meaning a single mom calls you and you state your fee is $50, a wealthy person in your community calls you and you state your fee is $500. We have to be clear about our fees. I

So, what does all of this mean for you? 

  1. You need to understand the specific laws and ethics in your state so you really understand what your responsibilities are.

  2. In many states, including California there is no requirement to have any sliding scale, but many ethical codes do suggest that you give back as a professional. You can determine how you do that.

  3. From a business standpoint, so you can develop a business plan, set clear clinical boundaries, have awesome clients, afford great trainings, get great consultation, etc. we recommend no more than 20% sliding scale.

  4. Non-profits and for-profits are very different entities, you can't replicate a successful non-profit model in a private practice. The taxes alone will put you out of business.


Have you struggled with how to set and stick to a fair fee as a compassionate clinician? Do you feel anxious every time you state your fee to a new client who calls, or feel frustrated that clients constantly try to haggle? Or, are you realizing your current fee isn't going to allow you to retire ever?