Sliding Scale Therapy: How It Works & Who It’s For

What Is Sliding Scale Therapy?

Sliding scale fee refers to a fee that changes based on income. Rather than their cost for therapy remaining set at a fixed rate, a therapist who offers a sliding scale has a cost range that “slides” up and down for individual clients. A sliding scale structure offers reduced fees based on client income and number of dependents.¹ This fee flexibility helps make therapy more affordable for those who would otherwise not be able to attend.

Does a Sliding Scale Work With Insurance?

A sliding scale structure can be used by those who don’t have insurance and have to pay for the entire cost of sessions out-of-pocket. It can also be utilized by those who are seeing a therapist that is not in-network with their insurance provider. There are some instances in which someone can utilize both insurance and a sliding scale rate, but these are rare and depend on the therapist and the insurance provider.

What Is the Average Cost of Therapy?

The typical cost of therapy varies depending on where you live and the type of therapy you need. Fees can range from around $100 per hour to over $250. Variables such as therapist type and credentials, specialty, and nature of the practice (private versus community-based non-profit organization, single therapist versus a suite of many) can influence the final cost. A sliding fee is relative to each therapist’s or organization’s rates, and will therefore differ from professional to professional.

How Does Sliding Scale Therapy Work?

Each therapist or organization determines whether to offer a sliding scale fee structure. While many individual therapists do use sliding scales, income-based rates may be easier to find in community settings because public organizations are frequently funded or subsidized by outside sources. Fee structure has nothing to do with a therapist’s level of caring or concern for their clients.

Why Wouldn’t a Therapist Offer Sliding Scale Rates?

It is often not practical or even possible for a therapist to offer a sliding scale. There are a number of reasons preventing some therapists from varying their rates, including:²

• Ethical concerns: Certified and licensed mental health professionals must adhere to a strict code of ethics. Each organization has its own ethical guidelines. Some groups or individuals may deem it discriminatory to charge people different fees for the same services.
• Client perception: Similar to ethical considerations, some therapists are hesitant to send the message that they are gouging people for their services, requiring some clients to pay more than others. And just as those who discover their cost is higher may be resentful, clients not paying as much may feel a sense of shame. Some therapists choose to avoid this by setting a single fee for everyone.
• Insurance restrictions: Some insurance companies don’t allow their network providers to offer varying rates and if therapists do so anyway, they risk being charged with insurance fraud.

How Are Sliding Scale Therapy Fees Calculated?

While therapists may use unique methods to calculate sliding scale fees, the rate is determined logically and with a formula. If someone doesn’t use any type of formula, that’s a red flag that they’re not a great therapist. With this type of flexible fee structure, expect a therapist to have a maximum and minimum charge. What you pay will fall somewhere in between the two extremes.

Therapists often determine their sliding scale fees in the following way:

• First, the therapist will determine their set maximum and minimum rates for everyone. The upper limit is based on the customary fee for mental health services in the area as well as the therapist’s level of expertise, credentials, and experience. Their operating costs and financial needs establish their lowest practical fee.
• Then, they consider your unique financial situation, taking into account your income, number of dependents, and other special circumstances that impact your monetary needs.
• To decide a fair rate, many therapists use the U.S. Federal Poverty Guidelines: [.001] x [client income at or near the poverty threshold].^{2, 3} For example, if a client supporting three children makes $27,000 per year, a sliding scale therapist could use this formula to charge this client $27 per session, or their minimum fee.

This is just a guideline. Each therapist may vary in their approach. Some, for example, have a few levels of fees and assign certain income ranges to each level. It’s important to ask a therapist not just if they use a sliding scale structure, but how they do it. Some therapists use an honor system, trusting clients to fairly report their income and financial hardships. Others may ask you for proof of income or dependents, such as your previous year’s tax return. This is simply to keep the system equitable for all clients.

Do I Qualify for Sliding Scale Therapy?

Sliding scales exist to make therapy more accessible to those who otherwise couldn’t afford it. A sliding fee structure can be helpful for those who don’t have insurance and must pay the entire cost out-of-pocket, or if their therapist is out-of-network with their insurance provider. Even when someone has insurance, however, the cost of therapy may be prohibitive if they have a limited income, a large family, or regular medical bills.

Accordingly, rates are based on factors such as:

• Income
• Number of dependents
• Factors such as disability, chronic illness, or temporary unemployment

Do I Still Qualify for Sliding Scale Therapy if I Have Insurance?

Whether you can use mental health insurance to cover a reduced therapy fee depends on both the therapist’s policy and your insurance carrier. In some cases, you must choose one option or the other: using insurance or receiving a reduced rate.

If you are allowed to use a sliding scale and submit it to your insurance company, you will still be responsible for your insurance company’s standard copayment (copay). Also, you’ll be required by your insurance to meet their deductible before they begin to cover the cost of an office visit. This holds true, of course, regardless of whether you receive a reduced fee for therapy or pay your therapist’s standard rate.

Using both insurance and a reduced fee will mean that it will take longer for you to meet your deductible. Some people find it preferable to bypass insurance altogether and opt for a reduced cost per session.

It’s worth exploring your options to determine the best financial approach for you. Check with different therapy offices to determine the best rate and who offers sliding scales. Keep in mind, however, that there are many factors beyond cost to consider when choosing a therapist. Also, call your insurance provider or check their website. Ask if it’s possible to use your policy if you are receiving a reduced rate from a therapist, what services and how many sessions are covered, and how far away you are from meeting your deductible for the year. This will help you know if it’s a better deal to pay for therapy out of pocket with a sliding scale or use your insurance.

How to Find a Sliding Scale Therapist

It can sometimes take a bit of work to find a therapist who uses a sliding scale for their rates. Sometimes, a therapist will indicate this on their website or professional profile in therapist directories. Often, though, they don’t publicize their fee structure; therefore, it’s okay to call their office and ask about payment policies.

You can ask about financial matters at any time. Even if you’ve begun working with a therapist and your financial situation suddenly changes (for example, you lose your job or experience a divorce from or death of your partner), you can ask for a temporary reduction in your session fee. That said, it’s advisable to ask about cost during your first call to a therapist’s office before you even schedule your first session. Know ahead of your call what you can afford to pay for therapy, and if a stated fee is more than you are able to pay, you can ask if they offer a sliding scale. Therapists expect people to ask about fees, and most are open and willing to have a conversation about what you can afford.

If you are unable to find a therapist in your area who offers flexible rates and you truly can’t afford to pay for therapy, you do have other options for your mental health.

How to Ask About Sliding Scale Therapy

Asking about a sliding scale option may feel uncomfortable or difficult. It can be helpful to know that many therapists reserve spots for clients who need to utilize a sliding scale fee and are happy to work with you to find a fee that works for both of you.

Here are some tips for discussing sliding scale options with a therapist:

• Know What You Are Able to Pay Before You Call: Look at your weekly budget and figure out what you can afford for weekly therapy sessions. This is important because sliding scale options differ from therapist to therapist—one therapist’s lowest sliding scale fee may be $20 while others may be $75. Knowing what you can afford before you call can help you find the right fit more quickly.
• Be Prepared to Discuss Your Financial Situation: Some therapists use specific formulas to calculate the sliding scale fee they offer based on each person’s situation. Basic information you may need to provide may include your annual and/or monthly income, current employment status, and number of dependents. The therapist may request documentation of your income and/or employment status.
• Figure Out When You Would be Able to Attend Sessions: Many therapists who offer sliding scale options will do so during non-peak hours. While the standard of care you receive will not be any different, the scheduling availability may be less flexible. Know your schedule so you can quickly figure out if the therapist’s availability will work for you.

Email Template for Asking a Therapist About Sliding Scale Fees

When reaching out to a therapist by email, be clear that you are interested in their services and need to understand what their sliding scale options are. You may mention that you saw they offer sliding scale fees and wanted to learn more about those options, or ask if they have any sliding scale spots if you didn’t see that information listed. The goal for an email inquiry about sliding scale fees is to understand what, if any, options are available to you.

Example:

Dear (therapist’s name),

I am writing because I am interested in potentially utilizing your counseling services. I saw on your website that you offer sliding scale fees. Due to my current financial circumstances, I wanted to ask what options you have around the sliding scale and if you need any information from a potential client in order to calculate a fee.

Thank you!

(your name)

Phone Template for Asking a Therapist About Sliding Scale Rates

When calling a therapist to inquire about their services, don’t hesitate to ask any questions you may have around their sliding scale options. While it may feel awkward or uncomfortable, therapists routinely answer questions about their services, including their fees. They will be happy to answer questions that help you both determine whether you might be the right fit.

Examples:

• “I know your fee is listed as $150, but unfortunately I’m not able to afford that right now. Do you have any sliding scale options available?”
• “I wanted to ask if you have any sliding scale options available because I can currently only afford a fee of $75. Is there a way we can make that work?”

Alternatives to Sliding Scale Therapy

Don’t abandon your search for affordable mental health care if you can’t find a sliding scale provider in your area. Consider the following helpful alternatives to full-length, individual therapy with a private therapist.

Ask the Therapist if They Have Other Financial Policies

Many ethics boards encourage mental health professionals to offer pro bono sessions; numerous therapists provide a certain number of free sessions to clients based on need.¹ You might be put on a waiting list or be offered appointments during non-busy hours, but you might find it worth it in order to see a specific therapist.

Sometimes, counselors offer partial sessions for a reduced rate. You might be able to receive 25-minute sessions rather than the typical 50-minute meeting for half the price. Likewise, some therapists may be willing to see you less frequently than they typically see clients. You might see a therapist once every other week rather than once weekly, for example.

Some mental health providers occasionally allow a bartering system in which you pay for therapy by providing a useful service of a different kind to your therapist.¹ It can sometimes be difficult to establish a fair trade, so many therapists avoid a bartering system. You can ask them about this option, and even if they decline, it may open the door to a different financial arrangement.

Some therapy offices have payment plans. Even if you must pay the full price, you might be allowed to pay in small increments over time so therapy doesn’t tax your household budget.

Employee Assistance Programs (EAPs)

Some places of employment offer EAP benefits that include a limited number of professional mental health therapy sessions. The exact number of sessions and therapists you can see varies according to the specific plan. In many cases, EAP benefits are extended to employees and any family member on the health insurance policy. Therefore, if your spouse or parent has an EAP, you may be eligible for a few free therapy sessions.

The service is anonymous, so you don’t have to worry about your employer discovering that you are seeking therapy if you want to keep the information private. The only thing that a therapist will disclose is the number of employees or dependents they see and the number of sessions provided.

Online Therapy

Often, online therapy is less expensive than in-person sessions and the best online therapy companies can often get you an appointment within a day or two. The primary reason for this is practical. Online therapists often don’t have the same business expenses as therapists who run an office. Most health insurance plans will cover online therapy and even subscription therapy services are starting to accept insurance. Online therapy platforms that take insurance will likely be the most cost effective option.

Group Therapy or Support Groups

Group therapy is sometimes less expensive than individual therapy because the therapist sees multiple people in a single session. Group therapy is provided by a mental health professional and is a form of structured counseling. Groups are carefully designed by therapists, and participants often must be invited to join. This is because group therapy isn’t right for everyone, plus for a group to be effective, members must fit with each other. In some cases, clients must be seen individually before becoming eligible for group therapy.

A support group, on the other hand, is typically run by non-professionals, often referred to as peers, and is often completely free. Leaders are usually people who experience the same mental health challenges as the participants. Support groups are places where people can share frustrations as well as solutions that have worked for them. To find a support group in your area, check with local mental health centers, online directories of mental health organizations such as the National Alliance on Mental Illness (NAMI), or use sites such as MeetUp to identify groups of interest to you.

University Programs or Teaching Hospitals

Graduate schools, medical schools, and teaching hospitals frequently offer free or reduced-rate mental health services to people as part of their education programs. If you participate, you’ll work with a therapist-in-training or a resident in psychiatry. Students are strictly supervised by professors who themselves are licensed or certified therapists, doctors, or other such professionals.

Community Mental Health Clinics

Non-profit mental health centers and clinics, including integrated health clinics that combine physical and mental health services often offer professional therapy at a lower cost than private therapists.⁴ Use the Health Resources & Services Administration’s online directory to find such a health center near you.⁵

Final Thoughts

While mental health therapy can be expensive, don’t let cost prevent you from working with a professional to improve your wellbeing and quality of your life. Your therapist might offer a flexible fee system in the form of sliding scale therapy, and if not, you have numerous alternative options available to you. Don’t give up on your chance at mental wellness.