In my CACREP-accredited master’s and doctoral programs in community and clinical mental health counseling, I received a thorough education in many areas but little instruction on how to establish a private practice. Foundational legal and ethical concepts are introduced to students in the classroom, and clinical experience is offered in practicum and internship, but students who choose to enter private practice after earning their counselor license must continue learning on an independent basis. Literature on the subject is scarce. Although some how-to books include a chapter on practical and business matters, they are mostly dated, and little has been written on the topic in professional journals.
I wanted to know more about how to establish and maintain a private practice, so I decided to ask some practicing clinicians. I began by compiling a list of topics and considered some professionals whom I respect. I wanted to discuss matters with people who “have what I want,” both professionally and personally, so I completed my list of interview topics and determined whom I would interview.
I chose three graduates from my doctoral counseling program at the University of North Texas. All three counselors see clients in the Dallas/Fort Worth area and have been working in private practice for at least 10 years. Counselor One sees children, adolescents and adults. Counselor Two manages her own intensive outpatient program specializing in the treatment of eating disorders. Counselor Three works full time with adolescents in a suburban public school but also sees individuals, couples and families in private practice, where he shares office suites with other independent private practitioners.
The interview topics I choose included building a referral base, thinking about caseload considerations, scheduling and variety, maximizing income, minimizing overhead, practicing self-care, billing and collections, and developing partnerships. Some of these topics had been written about previously in the literature. Other topics included subjects I had not found addressed in the professional literature.
Please note that the information in this article presents merely the experiences and opinions of the counselors I interviewed. It is not meant to suggest that these are automatically the “right” steps to follow when entering and setting up a private practice.
I began with a discussion of marketing, specifically what has and has not worked in the past for interviewees. All three interviewees agreed that their best referral sources came from establishing working relationships with psychiatrists, primary care physicians and medical doctors.
Counselor One’s marketing efforts focused mainly on her relationships with primary care physicians and psychiatrists and on using her website as a resource. She reported reaching out to doctors and bringing lunch to offices regularly to begin and maintain relationships. She cited the significance of beginning with just one doctor who refers regularly. She also tried sending out letters to a new area, but that proved fruitless because she received no new referrals. Instead, Counselor One emphasized the importance of face-to-face contact and tokens of appreciation. She also reported that the online Psychology Today referral service brought her approximately one to two clients a months, making it a worthwhile investment.
Counselor Two also has a website but cited primary care physicians as her primary referral source. She talks to about 10 of these professionals on a regular basis. She wasn’t a proponent of advertising through online referral services such as Psychology Today or Blue Cross because she said they wouldn’t designate her as an eating disorder specialist. This resulted in many people contacting her for generalized services that she was not in a position to provide.
Counselor Three reported relying on his reputation as his main marketing tool, although he also cited his website and reaching out to primary care physicians and psychiatrists. He said the most important thing in his career has been the reputation he has built for himself through community service and volunteer work. This focus has provided him with many clients through word of mouth. When clients come to him from a primary care physician or psychiatrist he isn’t familiar with, he reaches out to that professional to establish a working relationship, both for the good of the client and to build a foundation for possible future work together. He reported solid relationships with four psychiatrists and many more primary
Counselor Three also cited location as being key to his marketing through the years. He chose a suburban area where he had identified the need for counseling services after conducting research via the Internet and driving around and scouting locations physically.
Regarding specialty, Counselor One and Counselor Three recommended that counselors advertise their services with a happy medium between specialty and general counseling. They cited the importance of variety, both for financial and personal interest reasons, but they also mentioned competency, ethical reasons and personal reasons for choosing a specialty. Counselor Two expressed the importance of choosing and sticking with a specific area of practice in the interest of competency. She also pointed out that clients are quite savvy in choosing a specialist.
Best business practices
Our next topic of discussion involved best business practices, an area that we broke down into particular subjects of interest.
All three counselors discussed receiving some form of guidance or mentorship upon starting out. Counselor One reported having a mentor from whom she learned a great deal while working in her first private practice setting. Counselor Two cited learning from other professionals in private practice. Counselor Three described accumulating significant knowledge from the collegial relationships he had first established during his time in the doctoral program. He reported asking these individuals what had worked for them. He recalled consulting regularly with two colleagues who were already in private practice about what he should expect.
Income and overhead
When asked what had been most helpful in maximizing income and minimizing overhead, Counselor One recommended being realistic when starting a private practice and taking into account how much time a practice will take to build. She suggested having other forms of income when starting out and not buying everything for the practice at once. She reported that it took about a year for her practice to become her primary source of income. She acknowledged that accepting insurance might have expedited that process but also said it could have made her practice less lucrative and more of a hassle.
Similarly, Counselor Two recommended not buying everything for a practice at once or anything that is not absolutely needed for the business. She also cited the importance of building a referral base through outstanding service.
Counselor Three cited the importance of building his reputation through word of mouth. He reported performing a great deal of volunteer work in the community, including in schools, which led to a consulting position that turned into a full-time position. He also emphasized the importance of developing a strong network of people within his practice who are competent and trustworthy.
All three counselors reported sharing office space or rent with other practitioners at some point in their careers. Two counselors reported providing supervision services, and two reported sharing a practice with others.
Counselor One described her caseload as consisting of 20-23 clients per week, with approximately 40 percent of the clients being children, 30 percent adolescents and 30 percent adults. She sees mostly individual clients and small groups and also supervises a few interns. She reported working on a sliding scale fee when she started out, but she no longer does this. She estimated her average annual income at $90,000-$100,000. Play therapy is her primary source of client-generated income.
Counselor Two sees approximately 35 clients per week in addition to one group. She also supervises a few interns. She reported her estimated income as $2,000 on a good week and $800 on a bad week (and recalled her income being even more variable when she accepted insurance). Her primary clientele is made up of individuals with eating disorders.
Counselor Three reported seeing approximately eight to 12 clients per week on alternating weeks outside of his full-time job with an independent school district. In his private practice, approximately 75 percent of his clients are couples and families, whereas the remaining clients are individuals. He reported his estimated average annual income as $60,000 from the school and $500-$750 weekly from clinical work. He sees a variety of clientele in his private practice rather than specializing in one specific area.
All three counselors reported similar practices related to most administrative details. All three receive payment at the time of service. None of the counselors employs an office manager or bookkeeper, but two of them have used billing software such as EZClaim and Therapist Helper.
Counselor One reported enforcing a no-show policy by charging a reduced fee of $60. Counselor Two acknowledged not enforcing her no-show policy because she found it created resentment among clients. At the same time, she stated that nonattendance has rarely been an issue with her clients.
None of the counselors I interviewed currently accept insurance. All three accepted insurance at some point in the past but said that it caused too many inconveniences and was generally more trouble than it was worth. Counselor Two was particularly outspoken about not accepting insurance, describing her experience as “horrible” and stating that “firing” her insurance company was the best decision she had made in private practice. The overall consensus seemed to be to avoid accepting insurance if that scenario could be financially feasible for the private practitioner.
Words of wisdom
To close my interviews, I chose to focus on words of advice, including asking what the counselors might do differently if given the opportunity to start over.
Counselor One stated that she would meet with a financial planner and an accountant to better her understanding of taxes and tax breaks. Counselor Two said she would follow her same path — specifically, taking the necessary time to build a practice, asking other professionals what they had done and working hard. Counselor Three responded that he would hire a consultant, accountant and financial planner or marketing person at the outset to help him better prepare.
I also asked the three counselors to share the best practical advice they had received upon graduating regarding working in private practice. Counselor One said that no one had given her any practical advice about entering private practice. Instead, she recalled her husband being her biggest encourager and even buying her office furniture. She advised me that building rapport is everything in private practice and that the business side of counseling is about selling yourself.
Counselor One also provided some recommendations. For example, she advised against hiring office staff to handle phone calls. She believes it is important for private practitioners to do this themselves to keep things personal, to ensure clients are treated well and to not come across like a used-car salesman. She also warned against carrying clients who are not putting in the work. “It’s not worth it,” she told me. If clients don’t seem to want services, her opinion is that the best thing to do is let them go. Likewise, she advised me to watch out for practice groups because some may look to take advantage of private practitioners. According to this counselor, warning signs include taking more than 40 percent of collections and having clauses stating that former employees cannot work solo within a 50-mile radius upon leaving the group and cannot take clients to new locations. She also emphasized that it is vital for counselors to know with whom they are going into business. Counselors should research and know these individuals well before making any commitment, she said. She closed by citing her faith as the thing that has sustained her most, stating how important it has been for her in gaining acceptance and feeling grounded.
Counselor Two advised against working with insurance companies. She cited numerous examples of insurance companies creating problems for her private practice, including micromanagement, bureaucratic mazes, inaccurate advertising of her specialty and nonpayment for services. She also recalled that when everyone discouraged her from working in private practice, she found it all the more enticing.
Counselor Three said that the best advice he received was to work hard, to work ethically, to have faith, to be humble and to communicate well. He said that it is good for private practitioners to be generalists but that it is also wise to have a few specialties. He also recommended that aspiring (and established) private practitioners consider attending local conferences and workshops to network.
Where I plan to go from here
As I consider my literature review and the interviews I conducted, many things come to mind. First of all, I am glad that I have begun to consider my options. All of my interviewees said that now is the perfect time for me to begin reaching out to the public arena, networking and finding out how my colleagues and professors have established themselves.
These interviews have also spurred my curiosity to ask the same questions of other counselors. The process has left me with the desire to continue expanding my knowledge, experience and personal brand. As a way to repay what has so freely been given to me, I also plan to go forward and always be willing to share what I know with others.
Bryan G. Stare is a doctoral candidate at the University of North Texas. Contact him at firstname.lastname@example.org.
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