What Is a Sliding Scale for Therapy?

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What Is a Sliding Scale?

Therapy is expensive, with cash rates in the United States averaging from $50 to $150 per session (and up to $250 or more per session in some parts of the country). Many uninsured Americans live below the poverty line and are unable to pay these rates out of pocket.

In order to meet need in an affordable way, many therapists offer sliding scale fees, which means that a client’s fee is based on their ability to pay rather than a standard rate.

If a client does not have insurance (or cannot afford their deductible), their therapist might offer reduced out-of-pocket fees to make therapy more affordable. Although therapists are not required to offer a sliding scale, the American Psychological Association's ethical guidelines encourage psychologists to reserve a number of spots in their practice for reduced rate or pro bono services.

Although most therapists want to offer affordable care to clients, they have bills as well, and so typically a therapist will have a limited number of sliding scale spots available. Some therapists even offer free therapy sessions to low-income clients; however, some will include a small fee (for example, $5 per session) to increase client investment in the therapeutic process without creating financial hardship.

Navigating the Costs of Therapy

Verywell Mind's Cost of Therapy Survey found that among individuals seeing a therapist, about half are worried about paying for treatment long-term, and about one-third have canceled or reduced the frequency of sessions due to cost. The appetite for alternative payment options is high.

Despite those financial challenges, only 36% of individuals say they have ever negotiated their therapist's fee. Meanwhile, 44% of Americans in therapy have never even heard of sliding scale payment options for therapy.

What Sliding Scale Can Help With

Living in poverty is incredibly stressful, and research has consistently shown that those living in poverty are at higher risk for mental illness than those with a sense of financial security. At the same time, therapy is less accessible to those in poverty due to the high cost.

Furthermore, some with severe mental illness symptoms might not be able to work, which not only limits income but significantly inhibits access to health insurance. Even those with insurance might have a high deductible that they cannot afford to pay before their benefits start covering sessions.

Sliding scale therapy makes mental health services available to everyone, not just those who can afford to pay the fee. When clients have the option to pay based on a sliding scale, accessibility to mental healthcare increases.

Things to Consider

Therapists who offer sliding scale fees typically list these rates on their website. However, they might have extra flexibility depending on the unique circumstances. If the listed rate seems unaffordable, it never hurts to ask if there is any wiggle room in the rate.

For example, a client might have a significant amount of medical debt that they are working to pay off, so their true available income is much lower than their pay stub might imply.

Therapists might also be willing to work with clients on payment plans. If a client has an insurance deductible of $2,500, for example, they might not be able to afford $150 per session until they hit that limit; however, they might be able to afford $150 per month. A therapist can bill insurance and accept deductible payments until the balance is paid off.

A third consideration is a client’s mental health needs. Certain conditions, such as severe dissociative symptoms or eating disorders, may require a therapist to have specialized training in order to provide competent care.

In a case when a specialist is needed, therapy that is not specific to the client’s needs can be as bad as not receiving care at all. If an individual’s mental health needs indicate specialized care, the therapist will provide referral information rather than continuing services.

Specialists also often offer sliding scale fees, and having a specific diagnosis does not mean that affordable therapy will not be available. It simply means that, when finding the right therapist, the client will have to consider sliding scale availability as well as specialization in their diagnosis or presenting symptoms.

How to Get Started: Finding a Therapist Who Offers Sliding Scale

Many therapists provide a brief phone consultation at no cost to the client so that both parties can assess whether the relationship might be a good fit. During this consultation, the therapist will ask things like why the client is seeking services, what symptoms they are experiencing, and how they will pay for services.

It is appropriate to ask the therapist about their rates, whether they offer sliding scale fees, and what their policies are about payment plans. If a client requires sliding scale options for therapy, it is important that this is discussed prior to the first session.

If the client cannot afford the therapist’s rate and attends a first appointment without discussing this in advance, they may still be responsible for the fee for that session. Transparency, honesty, and open communication on the part of both the therapist and client is essential.

If the therapist determines that they need to make a referral because they do not specialize in the client’s needs or they are not able to accommodate the client’s financial situation, it is appropriate for clients to ask about the referral’s credentials and sliding scale options. The therapist making the referral might not have all of this information, but they will be able to provide the client with contact information.

If a therapist offers sliding scale fees, this information may be available on their website, along with specific requirements such as household income, number of family members in the household, and whether or not the client must be uninsured to request a sliding scale rate.

Although a therapist is not required to provide a sliding scale rate to anyone who asks, they have an ethical obligation to provide referral information if they are unable to meet a client’s needs.

Open Path Collective is an organization that connects people to low-cost therapy sessions starting at $30 per session. Clients can search for providers in their geographic area that can meet their mental health needs at a price they can afford.

Sliding scale fees are an important step in making mental health services affordable and accessible to everyone regardless of income and financial resources. If you cannot afford the cost of therapy, services can still be available at a rate that you can afford if you know where to look.

3 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. National Health Service Corps, NHSC Sliding Fee Discount Program Information Package, June 2019.

  2. American Psychological Association All rights. Ethical principles of psychologists and code of conduct. June 1 E date, June 1 2003 with amendments effective, 2010, January 1, reserved 2017.

  3. Ridley M, Rao G, Schilbach F, Patel V. Poverty, depression, and anxiety: Causal evidence and mechanismsScience. 2020;370(6522):eaay0214. doi:10.1126/science.aay0214

By Amy Marschall, PsyD
Dr. Amy Marschall is an autistic clinical psychologist with ADHD, working with children and adolescents who also identify with these neurotypes among others. She is certified in TF-CBT and telemental health.