Private Practice Q+A (2021)
(I wrote this post a year or two ago, and am transferring to this blog from another.)
Hi! And welcome to the official private practice Q+A post!
There were so many things I stressed about when deciding whether or not to start a private practice. It took me a year to gather the courage to finally do it, and I'm so glad I did! It's been a great fit for my personality and I can't imagine doing anything else. It's been more manageable than I thought and less stress than I prepared for!
I hope some of the questions and answers below can help you on your journey to deciding if a private practice is right for you. If there are any questions you have at the end, feel free to email me or comment them down below. I'd be happy to write up a "part II" if needed.
Ultimately, remember that all of this is just my opinion and experience. The world of therapy can vary so much discipline to discipline, location to location, speciality to speciality, etc. What works for one person may not work for you and that's ok! There is no one "right" way to do this career path.
Ok, without further ado, let's dive into the questions.
"I would love a pros and cons list":
Hour flexibility: A lot of group practices will have a minimum amount of clients you need to see per week (usually about 15-20). This is due to the financial cost they take on with each employee, and if you are only seeing 5 clients a week, you may cost them more than you are make them. In your private practice, you get to choose how many clients you see per week.
Client flexibility: Some group practices will encourage you to work with every presenting problem as a way of gaining experience. (And you do gain experience through this!) However, in your private practice, you can be really picky about what presenting problems you work with and only see what you feel comfortable treating.
Work flexibility: In a group practice, you may be sharing an office with other clinicians and may only have certain days or hours available. In a private practice, you get to choose what days you work, what hours, and when you take time off.
You can make more money: In lots of group practices, you are giving 50%+ of the session fee to the practice owner. This is because of the building/office expenses, the marketing the owner does for you, the free supervision they provide, admin responsibilities they cover, etc. In private practice you are responsible for all those things, but you also get to keep the full session fee. Even with the added expenses, I still make more in my private practice than I did in previous jobs. (This would be something you'd want to calculate and compare to your current job, as it may not be true for you.)
More responsibility: Since it's your practice, you are responsible for everything. This includes all the tax deadlines, calculating your taxes, intake paperwork, assessments, marketing, and the initial set-up with new clients. If you don't enjoy the admin/managerial side of things and just want to see clients and go home, this can be a lot of extra work to do.
Difficulty getting clients: A lot of group practices have already made a name for themselves in the community, or they have the ability to accept insurances that you wouldn't be able to accept in private practice. Both of those factors can fill your caseload fast! But, in private practice, you are on your own to get clients, and you may not be able to get as many as you would like. (Keep in mind, I think this is also affected by what niche you work in.)
Variable income: You are only paid per client, and this can be a big change coming from a salaried job. Some months or times of year may be slower, or you may have difficulty maintaining a fully caseload. It can be stressful to not be able to predict your income.
"Did you create your informed consent and required documents yourself or use templates online?"
Good question! I wrote them myself after looking at a bunch of templates online. There is a lawyer in my area who frequently works with therapists (and who I think is also licensed as a therapist himself!) who I had him go over them as well. It can be pricy to hire a lawyer, especially when you are just getting set up. But, I am very much a "cover your ass" type of person and found the investment to be worth it for the peace of mind it gave me with all the legal stuff.
"Do you only communicate with clients through email? Or phone/text? Do you have a work phone?"
I primarily use email! I do have a phone number through Google Voice that people can call/text. If you do this, you will have to ensure it is all HIPPA compliant.
"How long did you work for someone else before having your own practice?"
I worked at 3 different group practices for 2 years after I finished graduate school before starting my own. I'm honestly really glad I did that, as it was good to see the different ways a group practice can be run and gave me ideas for my own one day.
I also think it was helpful to grow as a clinician without the stress of running a business. So much learning and forming your clinical identity takes place those first few years. (And still after that!) Being able to fully focus on my clinical identity was so helpful to feeling confident in my abilities today. That being said, I think everyone recommends the path they took haha.
"How long were you fully licensed before you started your own practice?"
I wasn't fully licensed!
State to state there are different rules on licensing and private practices. For example, in Utah, associate level therapists can not start their own practice. However, in Washington, associate level therapists can start their own practice. You'll want to check the licensing laws in your state/the state you plan to move to after graduation to see what's up. You can also join a therapist Facebook group for that area and ask around in there.
"How long did it take to fill up your practice with private pay clients? If you are doing self-pay clients, how do you get clients?!"
I'll preface this with a theory: I think the niche you work in AND the area you're located in can largely impact how quickly it takes you to fill up. I'm located in Seattle, which has a relatively high average income. I'm also in a relatively small niche (there are not a lot of therapists here who work with eating disorders).
I was full with private pay clients a month or so after starting my practice. However, I worked at a group practice before starting my own, and the owner believed in allowing clients free will in whether or not they followed me to my new practice. So, I had some from there follow me to my new practice. (Side note: This would also be something you'd want to check out before leaving a job, as I've heard of a variety of opinions. Some group practice owners discourage therapists from seeing clients who want to follow them, other say it's unethical to tell client's where you are moving to, but if they find you on your own they can continue care.)
As for how to get self-pay clients: In the state of Washington, associate level therapists can't accept insurance, so I didn't have a choice but to do self-pay. Once again, your area is going to matter a lot. Higher average incomes mean you have more people who can afford to pay out of pocket. Also, your niche is going to matter too. The more therapists in your niche, the more competitive it is and the harder it may be to get self-pay clients.
"How many clients is it realistic to see per week? How many clients is too many for adequate care?"
This is going to be different for everyone. Things to keep in mind are how long it takes you to write notes, if you offer free consultation sessions, commute time, breaks, etc. For me, 20-25 feels great! 26+ and I start to feel really frazzled and busy.
As for how many clients is too many for adequate care... this is hard. I'd say when you get to the point that you can't remember what is going on with your clients without like, extremely detailed notes to remind you, it's maybe too many on your caseload. I feel like you want meeting with your clients to feel like resuming your spot in a book, without having to flip back a few pages to remind yourself of the storyline.
"How many clients can you see per day?"
I used to do 5-6 pre-pandemic when things were in person and I liked that! Keep in mind, my sessions are typically 45 minutes, so in the 15 minute break I was able to use the restroom, write notes, or have a snack. (Let's be honest, I never wrote my notes and always snacks and browsed Instagram haha.)
However, once I was doing virtual/pandemic-ing and I had some medical complications due to my pregnancy, I could only do 3-4 a day. TOPS. Once again, everyone is going to be different and you'll just have to play around with it a bit to see what works for you. It's easier to scale up than it is to scale down. So, when in doubt, start with less than you think you can handle.
"How do you manage your clients when you want to go on holiday?"
I just give them as much notice as I can (usually 3+ sessions) and make sure they have referrals if they need them. The population I work with tends to be relatively high functioning and this has never been a problem. However, I do know of therapists who have had their clients continue sessions with a colleague while they are out of town.
"What boundaries do you set with clients?"
I'm not sure exactly how to answer this one, so please DM me if this was your question and I miss the mark. I basically set all the standard boundaries you could expect. My paperwork goes over confidentiality stuff and financial obligations. When I meet with clients for the first session, I again let them know about confidentiality, what happens if we see each other outside of session, mandatory reporting, etc. My cancellation notice is no fee for anything at least 24 hours in advance, and the full session fee for anything less than that.
On a personal level, I rarely self-disclose in sessions. My take is that clients are there to talk about themselves and their lives. Sure, we'll chit chat for a minute walking to the office, but aside from that I want clients to feel like my office is the one place in life where they don't have to consider someone else's feelings/opinions and they can just talk freely about themselves.
"I'm new to the field and really wanting to start a private practice, but am nervous about a lack of experience. Can you talk a bit about this?"
I felt the same way! Like I said above, I feel like it is important to feel confident in your clinical skills before starting a private practice. I feel like a lot of learning takes place after graduate school, and it's nice to have the free mental energy to spend reading, researching, and learning that first little bit. For me, a "little bit" was about 2 years. My supervisor made a comment about how he could tell I was ready to become fully licensed, because our sessions went from me saying, "Here's the problem, what do I do??" to "Here's the problem, here's what I did." It changed from me asking him for advice to me updating him on clients, and that's about how it should be! I think there will always be a little bit of that "what am I doing" feeling, but ideally the more experience you get, the more confident you should feel and the less hand holding you should need. Once you feel confident standing on your own, that's when I'd say you may be ready to start a private practice.
But again: You'll probably always feel a little bit of imposter syndrome if you therapist-ing right! I think a huge part of this career is always having a learner's mentality and being up to date on the newest information. We don't ever really "max out" on education, and I think that thirst for knowledge and continual improvement is what makes a good therapist!
"What's something you wish someone had told you prior to starting a private practice?"
The negative: I did know this before, but feel it's important for people considering private practice to know: It can be really lonely! I know that's kind of a "duh" thing, but seriously think about how much social interaction you get from work. Even if it's just small talk! Yeah, you may have a few minutes of small talk with clients, but clients aren't your friends and it's a much different vibe. A full day in private practice can, ironically, feel like you just spent hours alone . So, make sure you have social supports in other areas of life!
The positive: Honestly, I wish I heard more about how easy and doable it is!! I think private practices can be really overwhelming, if you choose for them to be... but they can also be so easy. The hardest part is setting up all the paperwork and doing all the legal stuff in the beginning. I can also see it being hard if you're not a very organized person, as there's lots of tax due dates to consider. I have an entrepreneur personality and love independence, and for both of those personality traits it's such a great fit.
Ok! I hope this was helpful! Overall, I just want people to know that private practice is doable and really not that scary. You can do it if you want to! Everything is going to be hard in it's own way, but as my therapist always tells me, "It's better to screw up on your own terms than on someone else's."