What Is Your Cancellation Policy?

Oct
19
2009

Have you given any thought to What is Your Cancellation / No Show Policy?your cancellation policy?  If not, you should. Cancellation policies provide clarity for your clients and reinforce professional courtesy and boundaries for you.

It is common for mental health professionals to require a 24-48 hour notice for clients to cancel a scheduled appointment.  Under such a policy, the client who fails to give appropriate notice for canceling an appointment typically pays the therapist’s usual and customary fee.  Therapists who implement this type of policy often stipulate exceptions for emergencies and illness.

My cancellation policy reads as follows:  ”  A cancelled appointment delays our work.  When you must cancel, please give me at least 24 hours notice.  I am rarely able to fill a cancelled session unless I know at least 24 hours in advance.  In you are unable to provide at least 24 hours notice when you cancel, you will be charged the full fee for your session unless I am able to fill it with another client.  (You should note that insurance companies do not typically reimburse for missed appointments.)  The only time I will waive this fee is in the event of serious or contagious illness or emergency.”

Should you decide to implement a cancellation policy in your practice, make sure that you include it in your written statement of disclosure.

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Comments

  1. Wow! So interesting that you posted this today because just last night I was thinking about “Hmmm, I wonder what my cancellation policy should be? I should probably have one.” (I’m looking to start my own practice here in the next couple of months). I was thinking along the same lines as what you have in your policy (full fee if not 24 hours in advance, exceptions only for illness or emergency). I’m just wondering, however, do you find that anytime someone cancels it’s an “emergency”? Like do people come up with “my car broke down” excuses all the time? I guess there’s no way to regulate this and we just have to trust our clients when they say they are sick or have an emergency…I think probably the most effective part/biggest reason to have such a policy in place is because it means people will be much less likely to cancel in the first place. I bet you don’t have too many cancelled appointments, right?

    • Bkhappyfriday, welcome! And, thanks for dropping in to chat!

      Before implementing a cancellation policy, I had clients cancel on the spur of the moment or simply “no show” because they decided to “go out shopping” with a girlfriend, “forgot” about the appointment we had, or “just didn’t feel like working.”

      Those things don’t happen any more and here’s the reason why . . . . If clients aren’t self employed, they don’t often think about things from the perspective of the self employed. Before I was in private practice, it never occurred to me that by canceling my haircut or dentist’s appointment that someone else might be losing money. I just never thought about it . . . and probably canceled on the spur of the moment much more often than I would like to admit.

      However, once I learned (from personal experience) that that sudden cancellation hurts . . . I changed my behavior and your clients will, too. It’s been years since a client stood me up. And, when she did, it was material for us to explore in our session.

      If a client believes that a broken fingernail or needing to get a massage is an emergency, then I believe we need to be talking about it. Sometimes those things perceived by clients to be emergencies may be indicative of holes in their boundaries . . . like not being able to say “no” to a friend who drops by and wants to go shopping; sometimes, they may be indicative of difficulty prioritizing.

      My clients hear me often stress the need for them to learn better self care. If getting her nails done or getting that massage is what she prefers to be doing than seeing me, I actually encourage that even if there’s not 24 hours notice.

      Don’t get me wrong . . . those aren’t ever emergencies and I don’t waive fees for those things. However, neither do I shame my client or set her up to call them emergencies. I charge my fee (and clients do pay for them) but I frame such incidents as “prioritizing self care” and “choosing what is in their best interest” and those are things that I want my clients to value.

      Bkhappyfriday, I hope you’ll join back in as we continue to build our community!

      Think about it . . . . If my client is going to pay $100, would you rather she pay the money and sit through a session with you when she would rather be elsewhere? I think not! I think it makes much more sense for her to pay her money (because she committed to do so) and then to be exactly where she prefers to be . . . in a bubble bath, out shopping with friends, or whatever!

  2. Hi Tamara,
    Thank you so much for your quick and thorough response. Everything you said makes a lot of sense. I would definitely rather that my client do what is most therapeutic for them, and I also think cancelled appointments can be a great thing to explore in therapy. It also feels good, as a therapist, to recognize my own worth and have boundaries (like cancellation policies!) in place.
    I’m so excited to have found this great resources and I look forward to your future posts.
    Niloofar

    • Niloofar, feel free to introduce yourself and tell us about yourself. It’s a good way to start getting a little publicity . . . even for those who are not out of school yet!

  3. Laura Wilson says:

    I am trying to decide re cancellation policy in a new practice. I currently practice in another location and despite my cancellation policy, people cancel late quite often. Total cancellation rate per week is 25% most just in time to meet 24 hr cancellation policy which isn’t really enough time to do much with. This means that I can lose almost a days worth of income per week. I’ve been considering a 48 hr policy but cannot find anyone in my area who does that. I notice that you say 24-48 hrs on the site but you only use a 24 hr. one. I would be interested in feedback

    • Hi, Laura! Thanks for dropping in to join the conversation. Wow – 25% cancellation rate in a week is not the way to go, for sure! I use the 24 hour mark because I have virturally NO cancellations. However, if I started getting many, like you, I would not hesitate to use the 48 hour limit. And, I wouldn’t think twice about what other therapists are doing. This is about training your clients to abide by your boundaries . . . . 48 hours is not uncommon for professionals to use . . . even if they are not doing so in your area. (However, you might want to indicate below where you are so that others in the area that might be using a similar cancellation policy can compare to yours.)

      Laura, is it possible that there is another reason for so many cancellations? I don’t have a clue about your particular circumstances but here’s what I tell other professionals who struggle with this issue. (1) It’s really important to put your cancellation policy in writing in your disclosure statement. (2) You absolutely must discuss this as part of your process for informed consent. (3) You must act as a professional at all times including dress, speech, behavior. To do otherwise, gives the impression that you do not need to be treated as a professional. (4) I tell clients that ours is a professional “relationship” and that I value and respect their time and that I expect them to value and respect mine.

      What I know is that unless you are in business for yourself – especially in a service-oriented business – you may not realize the impact of no shows on a business. Usually when I explain to a client that a no show every day results in a 20% loss of income, that comes as new information. If the client and I have built a solid relationship built on respect and empathy, the client doesn’t stand me up. And, yes, I consider less than 24 hours to be “stood up.”

      I hope this helps you clarify what you want to do about your own cancellation policy. If I’ve missed the mark, Laura, and your situation is decidedly different, I hope you’ll drop back in to clarify. I’m happy to help you problem solve with this situation because certainly you are not alone!

      Looking forward to seeing you back here at Private Practice from the Inside Out! Have a good day!

  4. Laura Wilson says:

    Thank you. I am in Covington, GA. I do have the policy clearly stated in my informaed consent and review it with them. I always dress professionally and, I think, behave as such. I keep my boundaries clear. People who have been with me a long time, rarely cancel and to late cancel is pretty rare and some will even say “I know I owe you”. The worst cases are pretty new people. The absolute worse ones are people coming in on an EAP. I do see a lot of EAP folks and, at this point, take insurance. I think that does make a difference as I experience more of a sense of entitlement with those folks than with self pay. I have even had people say to me “why do you need my copay when you get all that money from insurance.” Of course, I explain that their copay is anyway from 25% to 75% of the total pay that I will receive. Many folks put us in the same category as doctors and seem to think that doctors are raking in the dough and are angry at the costs of health care. I usually try to talk with them about that and gently educate.

    • Hi, Laura, and welcome! Thanks for following up to let us know what you decided to do with your cancellation policy!

      My experience has often been like yours with clients initiating the conversation with “I know I owe you . . . .” I do love clients that are willing to be responsible for their own behaviors!

      I have found that my clients who are already self employed (or have partners / spouses who are self employed) rarely take issue with my cancellation policy and fees. It’s the clients who are employed by other people that seem to be most surprised / displeased. Once I explain both the relational aspects (including trust and mutual respect) along with the costs of running a clinical counseling practice, they almost always apologize and pay up.

      That makes sense to me because until I was in private practice, I didn’t think twice about rescheduling on the day of an appointment with with my dentist or hair salon. But the first time or two I got stood up or a client called to reschedule so that she could go shopping, I got it. I got what it meant to a sole proprietor’s income when a client is unable or unwilling to honor their commitment to an appointment. That’s all it took for me to change my behaviors. Now, if I’m not contagious, I keep my appointments and I expect my clients to do the same.

      Repeated no shows and last minute cancellations just don’t happen in my practice. I’ve set a clear boundary.

  5. Thanks for the post Tamara. I have a clearly stated cancellation policy, but I have been thinking about rewording it, and that is how I came across your post.

    I am a marriage and couples counsellor and part of my work involves helping people take responsibility for their actions and to have consideration for others. I feel enforcing a clearly stated cancellation policy is helping them to take these attitudes with me.

    My problem right now is that I don’t take credit card payments and it seems that this is necessary in order to enforce the policy (any suggestions here would be welcome :)). It seems that some people have no qualms about not showing up if they know you have no way to charge them.

    • Hi, Jean! Thanks for dropping in tonight!

      I agree 100% that a clearly stated cancellation policy (and follow through with enforcement) is as much a clinical issue as it is a good business practice. I have at different times accepted credit cards and not accepted credit cards in my practices. However, that has not in any way interfered with my cancellation policy. I’ve always been able to collect my fee for no shows and late cancellations. It is important to have your policy in writing and to discuss it as part of getting informed consent. Then when a client cancels at the last minute (or doesn’t show for an appointment), I usually mention while talking to the client (or in leaving a message on voice mail) that s/he doesn’t need to worry about mailing in the payment. S/he can pay the fee for that missed appointment at the next session. Assuming the client returns for a future visit, I ask them to write a check for the full amount.

      And, as you indicated, if there is no reason to cancel at the last minute, why wouldn’t you? Conversely, if you are charging your client your hourly fee, it’s most likely that they’ll do there best to show up and do some work with you!

      Jean, I hope you’ll drop back in often to chat and let your colleagues know about the community we are building here at Private Practice from the Inside Out!

  6. Hmmmn. I’m a therapist and a client. As a therapist I have a 24 hour cancelation policy and I find that it works well. My therapist has a 48 hour cancelation policy and it drives me crazy!!(not literally). I don’t know if it is because it is different than mine, and most people’s I know, but I tend to forget. I also tend to really examine my schedule for today and tomorrow, but not the next day. So sometimes I really am not sure/ready to plan to reschedule 48 hours ahead!
    I understand boundaries. But sometimes things come up the day before, and two days is just sometimes too difficult. I’ve seriously thought of leaving this therapist (who I have only been seeing about five months) just because of this policy. I know that sounds really black and white, but I can’t afford to pay for me not being there. And I never once missed an appointment with my last therapist who I was with for four years. Between my clients and life being unpredictable… I just don’t find 48 hours being realistic…

    • Hi, B! Thanks for dropping in to share both sides of the issue! You make a valid point. The further out you set that boundary, the more likely unexpected things are to fall into the mix. I wonder if you spoke to your therapist about this issue if she would reconsider her own policy. Since you have experience as a therapist and a client, I would think your feedback would carry additional weight with her.

      And, by the way, thanks for saying that you have your own therapist. There is such a stigma for mental health care . . . and even moreso for health care professionals who seek their own mental health care. I’m writing a post right now on self-care for therapists – something that was never even mentioned back in the 1980’s and 1990’s.

      I hope you’ll drop back in here often and contribute to the conversation as we continue to grow our online community here at Private Practice from the Inside Out!

  7. Hi Tamara, just a quick note. I use PayPal for the few credit card payments I receive for workshops and Skype sessions. PayPal is easy to use, and while the fees maybe a bit high I like the convenience. At some time, I may need to change how I process credit card payments but for now PayPal works.

    The cancellation policy is stated in my Client Services Agreement. The policy is reviewed with clients and they are asked to initial this section when they sign the Agreement.

    Dianne

    • Dianne, I agree with you. For low volume use, PayPal is a good option for psychotherapists.

      And, your cancellation policy sounds very well thought out. Do you get any flack about it? No one has ever complained about mine.

  8. I liked the comments here, and agree with the need for a clear cancellation policy. However, what was your response specific to the woman talking about EAP clients? I agreed that they were the “worst” because they get “free” sessions and if they don’t feel like coming, don’t.

    All EAP company’s have the therapist agree in writing that they won’t charge clients for missed appointments.Most EAP’s say the client just looses this appointment. The therapist looses the hour, and the fee. To get around this, I offer EAP clients the “same” privileges as my non EAP clients: pay my $60 reschedule fee, or loose the session as the EAP company dictates. To date, they all prefer to “loose ” the session. Any suggestions about how to work this better without getting in trouble with the EAP company??

    • Hi, Claire! Thanks for dropping in here at Private Practice from the Inside Out to chat! You know, I completely missed that Terry was asking about her EAP clients so thanks for bringing it to my attention.

      Unfortunately, whether you are working with an EAP or you are working with managed care, you typically sign a contract agreeing to certain conditions one of which is often, as in your case, not to charge for missed sessions. Claire, your policy of offering the same privileges, seems like a terrific way to get that “lost” session in. I wouldn’t have thought of that!

      I think the more useful question might be around how to get the clients to keep from missing appointments in the first place. One of the techniques I use to help some of my clients (the ones that are at risk of bailing early) to stay engaged in counseling is to predict that they’ll leave early. I say something like “I just want to let you know that I know that lots of times clients in your situation aren’t really completely ready for counseling. I know that because they typically leave before our work is done or find some other way to self-sabotage themselves. I don’t know if that fits for you or not . . . . But, if it is true for you, I want you to know that I’ll understand perfectly and won’t take it personally. If it’s not the right time for you, it’s just not the right time. . . .”

      What I’m doing here is talking about the elephant in the room i.e. his / her lack of motivation and setting up a double bind i.e. win / win in which, I hope, the client is more likely to complete his / her work with me.

      If you try this out, I hope you’ll drop back in and let us know how it works for you. And, if you guys have other suggestions for Claire and Terry, I hope you’ll drop back in and share them with us all!

      Claire, thanks again for taking time to comment here. It helps keep me on track as we build our online community and our bank of knowledge here at Private Practice from the Inside Out! I hope you’ll drop back in again soon – or sign up to receive email updates in your inbox!

  9. Laura Wilson says:

    As follow-up, it is true that you cannot charge EAP clients for No Show. Most EAP companies will support you having a cancellation policy and will usually count the No Show as one of their sessions. A few companies will pay the therapist. I state in my policy that if their insurance or EAP company does not allow me to charge them, I will not offer further appointments after two such occurrences. I do waive the policy if there is a death in the immediate family, if the roads are deemed impassable as in the case of severe weather, or if there is an emergency that warrants an immediate trip to the doctor.
    I have decided to use the 48 hour policy. I sympathize with the person who is irritated with greater than 24 hours, however, in my practice it seems that the folks who are that worried about the policy are the worst offenders. I agree with the suggestion of talking with the therapist about her situation. I certainly have some folks who stay with me for years and never cancel. I suspect most therapists are likely to work something out in those situations. One thing I have done is to have two prices. If they cancel less than 48 hours, it is half the standard cancellation fee. If they cancel less than 24 hours, then it is the full fee. This seems to be working out fairly well.

    • Hi, Laura! Welcome back! I love your creativity in having two different fees for your cancellations! I hadn’t thought of that and haven’t heard of anyone else doing that either. Nice out of the box thinking!

      As a private practitioner, you are able to charge whatever you deem to be fair. The only exceptions to this are if you have entered into legally binding contracts to that prohibit this. Assuming your contracts with EAPs does not conflict with your stated practice, your policy seems to be adequate.

  10. Susan Little says:

    I am a marriage and family therapist practicing in the inner city of NYC. I’m torn between 24 hours and 48 hours cancellation notice. Sometimes I have parents with very young children who get sick at the last minute resulting in cancellations, especially during the winter months or last minute daycare issues. What is a good way to address the cancellation policy during the 1st session with those who have young children and when they don’t abide by the policy?

    Also,  I have an office policy regarding pay the session fee at the begining of each session. My patients don’t follow this policy and i don’t know how to reinforce it after ts been discussed in the disclosure statement. I don’t have a receptionist. What are some ways you would reccomend that I address this issue with patients?

    I hope you don’t mind, but as a new subsriber as I read the old blogs, I may have some questions.
     
    Thanking you in advance,
     

    • Hi, Sherly! Welcome back to Private Practice from the Inside Out! I love it when my subscribers drop in with questions, suggestions, and brilliant ideas! That’s what I’m here for!

      Concerning your cancellation policy . . . . First of all, there is not just one “right” way for a cancellation policy to be structured. In fact, I’ve been involved in a discussion on LinkedIn recently concerning cancellation policies and there are at least 15 different versions I’ve seen there! What is important is that you give some serious thought to what you want yours to be and that you be clear about sticking to it. The only difference between 24 and 48 hours is personal preference. I request 24 hours notice for the very reason that you state – things happen and my goal is not to get rich quick at my client’s expense. That 24 hour notice for me is about setting boundaries, being treated with respect, and not resenting my clients because they’ve stood me up.

      My clients receive their paperwork to read over and complete before they ever arrive at their first appointment. The arrive with it read and completed. At our first session, I ask if they have any questions about any of the paperwork, answer their questions, and then address the different sections of the consent form. When I get to the section on cancellations I state . . . “I request that you give a minimum of 24 hours notice by phone when you need to cancel / reschedule an appointment. I will always support you to do what you need to do to take care of you and your family. However, barring life threatening emergencies, if you are unable to provide the 24 hours advance notice, you will be charged my full hourly fee of $100. In reality, I do waive my fees for sudden illness and / or a lack of childcare. I have never had a client abuse those exceptions. If I did, that would then become a clinical issue to be discussed and a business boundary to be enforced.

      As for collecting your fees, I suggest that you walk into your waiting area or office to meet your client with your receipt pre-written as much as possible. Before you even sit down say “Let’s take care of your payment first so that we don’t have to cut off our work at the end to deal with money issues.” If you are working with brand new clients, they will assume this is just the way that you run your business. If you are changing this pattern with existing clients, then it’s perfectly OK to state “I’m changing a few things about the way I run my office. From now on, I’m going to start by taking care of your payment before we settle into our session. That will enable us to not have to stop in the middle of our work so soon.” By explaining this, your clients will feel taken care of . . . because you are doing this to protect your time together.

      Let me know if these work for you, Sherly! And, I’m sure there are other subscribers out there who can offer different suggestions. All suggestions welcome here!

  11. No-shows and last minute cancellations are the bane of all therapists. At first I was really nice about it “it’s okay! Things come up. Just give me more notice next time”. But then after repeated no shows I got fed up and decided to take action. I no longer take people with medicaid or medicare. That alone cut my cancellations in half. I then started a 24 hour cancellation policy except for emergencies. I noticed that the exception for emergencies thing didn’t cut down my no-shows because people would just make up excuses. Now my policy is $50 for late cancellations and $80 for no-shows. If they don’t pay it at the next session, they can’t see me anymore. No exceptions. I explain this in detail during the first appointment and have my voice mail say “If you are calling to cancel and are giving me less than 24 hours notice, I must remind you that you will be required to pay a $50 cancellation fee”. I also have form letters I mail (including another copy of my office policies) when people miss appointments, reminding them of the fee. Now I rarely get cancellations. It sounds mean, but you have to do this if you want to make a living. And if a client gets so mad about the cancellation fee that they don’t come back, then that is there decision. It’s better to get no-showers out of your schedule

    • Hi, Madea! It’s good to have your voice here! I can see that you’ve definitely taken charge of this issue in your practice! So glad it’s working for you!
      I am curious about your statement that since you quit taking clients who have Medicaid and Medicare, you have noticed that you have half as many cancellations. I’m really surprised by that number. Do you (or anyone else) has any hunches about that?

  12. Many offices such as optometrist and dentist call their patients the day before to remind them of appt.Can we legally offer this option and then say in a cancellation policy “You may be contacted 24 hours in advance and can cancel at that time.. If you choose not to receive a reminder call, then a $50.00 cancellation fee will be assessed? Any thought or feedback

    • Hi, Gail! It’s legal to call your clients assuming you have their permission to do so and you are observant of confidentiality. And, it’s certainly legal to have a cancellation policy that stipulates 24 hours notice (or any other time frame that you deem appropriate) is required. However, it is much simpler to say “If you are unable to give a full 24 hours notice, you will be charged for the time that was reserved for your appointment.”

      I am not an attorney, but I do wonder if by stating “you may be contacted . . . ,” you may be taking the teeth out of this policy. After all, you haven’t committed to being responsible for calling 24 hours in advance but you have stated that you will be charging the client anyway for that appointment. If you are really attached to the language that you’ve suggested above, Gail, I would suggest you run this by an attorney to see if it is really accomplishing what you want.

  13. Hello,

    I would just like if any of you has a cancellation policy that also provide for when it’s the therapist who cancels less than 24 hours in advance.
    And Tamara, what are your thoughts on the matter: should the therapist who cancels less than 24 hours in advance offer a free session, given that the client has also set aside that hour?

    • Hi, Lo! It’s funny that you should mention this. It’s not written in my cancellation policy but I do adhere to the same rules that my clients adhere to. Barring weather and emergencies, my clients are entitled to expect the same from me that I expect from them. If I stood them up or double booked an appointment, decided to stay home or take a trip, they can expect that they would receive financial “credit” for that mistake or last minute inconvenience. Absolutely!

      Is that your policy or your therapist’s policy? As the employer, I would think that any client would expect / require no less.

  14. Hi Tamara,
    I respect that, it makes sense.
    The reason why I was interested in the various cancellation policies is that my therapist recently cancelled a session at the last minute.
    I was really upset so she decided to disclose the reason for her “emergency”, which was an event she could have planned in advance so as to give me reasonable notice.
    I didn’t confront her on that as I wasn’t comfortable with her disclosure in the first place and I didn’t want to enter the details of it, but I do feel unjustly treated.
    I am sure in the long run we will resolve this issue, but in the meantime I am glad to hear that other therapists treat their own cancellations with the same fairness as their patients’.

    • Thanks, Lo, for continuing this discussion here. I know that I’m not perfect and I don’t expect the professionals I hire or the clients who hire me to be perfect either. However, I do expect all of us to be responsible for the mistakes we make and to clean up our messes.

      I do think that therapists and clients alike often forget that the client is the employer and the therapist is the employee. It would be wise for both to operate with the same understanding of the ground rules. It makes for a smoother process. So much of “success” in therapy is based on the actual relationship between the client and the relationship . . . . It’s often initially uncomfortable for a client to address the feelings that you describe – of being treated unreasonably, unfairly, or with disrespect. However, Lo, I would encourage you (and other clients) to take a look at what it is that makes you uncomfortable in broaching that topic with your therapist . . . .

      In my experience, those unspoken topics are often the keys to unlocking the patterns that keep us stuck. By saying that “in the long run” you expect to resolve this issue, you obviously have worked to build trust in your relationship with your therapist. And, who knows . . . perhaps your therapist is part of our online community here, will read this discussion, and recognize her own impact on her clinical work with you!

      Best wishes on your journey!

  15. My therapist recently mentioned offhandly that she has a new cancellation policy. Four weeks vacation okay then any cancellations other than that have to be rescheduled. This doesn’t seem to offer me any hiatuses from therapy, coming less frequently for a while, etc. I understand her need for secure income, but i’ve never experienced this kind of set-up, and it feels like my needs are being subordinated to her finances. Am i offbase here?

    • Sjw – I’m not really sure what you mean . . . . The frequency at which you see your therapist should be based on your needs and is, ultimately, your decision. Many clients benefit from breaks in therapy . . . to practice or solidify the material they have been working on, to re-focus / re-identify / clarify priorities, etc.

      Should your therapist disagree with that frequency, you should be able to have a conversation around the clinical reasons for that disagreement so that you and s/he both understand the costs / benefits from a break. The frequency you see a therapist should not be contingent upon your therapist’s needs – financial or otherwise. If I am understanding you correctly, I would suggest that you begin your next appointment with this very conversation. Perhaps there has been a misunderstanding?

    • why? ETHICS protect the CLIENT – OFFICE POLICY protects the practice. I pay my analyst whether I show or not. Why would a clients emergency in any circumstance become the therapists emergency? You go to yoga classes, you go to college classes….all those are paid by you whether you show or not. WHY ARE WE THERAPISTS continuing to be pious givers when we know this practice of “oh, it’s ok, emergencies happen” hurt our ability to make an income? I’ve been in private practice for 6 years – I’ve NEVER ONCE seen an insurance company offer me a raise. It’s tough going. Pay with the understanding the pay policy protects the practice – I’m here whether you show or not. I honestly cannot fill a space – that would mean I have to accept a new client and most of the time I do not have the room for one that occurs when you have an emergency. of course I do not say it like this, but I’m offering it here for conscientious thought – and self respect. No one pays for our sick days, ou vacation days, our days off for workshops/ceu’s and supervision/consultations on your case….we need to count on the income you agreed to accept the time. please pay.

      • HI, Chloe! Thanks for bringing in such a passionate point of view! I’m certainly not going to argue with you! My point was only that every therapist needs to consider ahead of time how he / she is going to handle cancellations and no-shows. I believe that too many of us make those “policies” of on the fly without giving adequate consideration to the clinical and financial implications that result. And, all too often, many are giving their services away without considering what that’s really about, too!

        Thank you for joining the discussion, Chloe. I hope you will be back often to bring your passionate voice to the conversations at hand!

  16. Hi all

    I stumbled upon this discussion while working on tightening up my cancellation policy. Until I brought in a formal policy a couple of years ago, I would regularly lose 50% of my income in a week. Ouch! Since establishing the formal policy I get only a few no-shows per year, and I’m happy to lose clients who frequently reschedule at the last minute (whether they pay or not), or worse, stand me up (only about 3-4 per year now).

    Now working on a pro-forma statement (one written, one verbal) for clients who stand me up. Am yet to find a magic formula to erase the stress of the experience though!

    Thanks for your great web site Tamara – I’m going to take some time to look through carefully.

    • Olwen! Welcome to Private Practice from the Inside Out! It’s always good to hear from my Aussie readers so I’m happy to add you to the list! (By the way . . . New South Wales is on my bucket list!)

      So glad you dropped in to talk about your no show and cancellation policy! As I’ve firmed up my policy, my no shows definitely dwindled. I’m glad to hear yours did, too.

      I hope you’ll be back often to look through my website and let me know if you need anything that you are not finding here! If you find this site to be useful, I hope you will tell your colleagues so that they, too, can join us here. I look forward to networking with you, sharing what I know, and learning from you, too!

  17. equilibrist says:

    I’m just now starting my private practice and struggling to come up with a cancellation and vacation policy that makes sense for me. (I notice most of the comments above have been about cancellation only, but vacation policy also seems important to me from the point of view of the therapist who is running a business and has to make a living.) I’ve been doing psychoanalytic training and seeing clients in a clinic setting for the last seven years, and the policy there is that ALL cancelled appointments, without exception, must be paid for by the patient. The only exception is two weeks’ vacation per year that the patient gets to take as s/he wishes, but not on the spur of the moment–agreed upon and scheduled in advance with the therapist. Individual therapists have the option of making up sessions for patients who want to cancel, but that is only at the therapist’s choice. For myself, I have always been willing to consider rescheduling (IF I have open hours) for a patient who tells me the week before that s/he needs to reschedule, but if it is less time than that (i.e. a call two or three days before), I am probably not going to be able to reschedule and the client will have to pay the full session fee.

    Now, trying to come up with my own policy, I’m caught between feeling that the clinic’s policy is somewhat inflexible (though I have seen my own analyst for 15 years with this same policy) and wanting not to lose income and have to resent or question patients for their cancellations. As I see it, if I allow my clients only two weeks of vacation per year, then it is not really fair for me to take three or four weeks off myself (though if I didn’t, I think I’d burn out!). I’m thinking about upping the vacation for both patient and therapist to three or four weeks each–but that means, in figuring annual income, I will only be earning money for 44–46 weeks a year at most.

    Also, it would be soooo much easier to offer patients a 24-hour cancellation policy, but I fear that would significantly diminish my income as well. I’m struggling to try to find some middle ground–a one-week cancellation policy (with the option of rescheduling if possible and desired by the client), but less than one week equaling full patient responsibility? Wondering if others feel that is too restrictive?

    When clients express surprise that they will have to pay for missed sessions, I often convey to them that this is their (our) time, one I have set aside uniquely for them–and I liken it to paying tuition for a class. Would they expect to get the money back for a class they don’t attend one week? In the same vein, since this is the client’s time, I also feel that it’s clinically important not to be changing or rescheduling that time very frequently–I think that also affects the treatment in all kinds of ways.

    Sorry this is so long! I wonder whether anyone has any thoughts or suggestions about the policies I’m considering? Thanks!

    • Equilibrist, welcome! And, thanks for joining this conversation! You are absolutely right in noting that a vacation policy is as important as an absentee policy.

      I’m hoping that some of the psychoanalysts here in our community will join in with some opinions as I am a psychodynamic but not psychoanalytic therapist. I think that may make a bit of a difference here in the opinions that come in. It makes perfect sense to me that you would not want to be less generous with your client than you are with yourself in granting down time. I do understand the clinical needs for consistency. But it seems that it’s your concerns about finances that are weighing most heavily here . . . . Do I have that right?

      I love your willingness to consider your work as a whole i.e. using the analogy of paying for a class rather than day by day so . . . I want to encourage you (and others) to consider charging accordingly . . . . Perhaps you can “package” your services differently . . . by the week or the month or quarters even rather than charging by the hour. You may find that this allows you to obtain the financial security you are looking for without having to collect your fees hour by hour. There is nothing magical about billing by the hour and nothing that says you need to do so.

      The other thing that you may want to consider (especially if you want to continue charging by the hour) is to increase your fees. I realize that it may be a scary proposition to do so but I find that most therapists fail to appropriately monetize their services and most often under-value the benefits that they bring to their clients. Just think about it.

      And, once you decide what you are going to do, I hope you will drop back in to let us know what you decide and why so that we can all learn from you. Equilibrist, best wishes on your journey!

  18. equilibrist says:

    Tamara, thanks so much for your thoughts, especially the intriguing ones about “packaging” my services in a new way. I’m going to think about that (though I think the upfront commitment will definitely scare some clients!).

    Re fee-setting, that is definitely something else I’ve been struggling with. I want to set my fee high enough to feel like I’m valuing my work, but it has felt arrogant to me to set my fee along the same lines as others who have practicing for much longer. My own analyst, though, who has been practicing for decades, encouraged me to set my fee not that much lower than her own–with the rationale that I received my graduate degree ten years ago and I have completed extensive postgraduate training, while others with my same degree (MSW) may choose to hang out a shingle right after they’ve graduated, without any experience or postgraduate training whatsoever.

    Another subject that has me confounded is insurance–not so much whether or not to join in-network panels (I don’t plan to, at least at first) but how to handle out-of-network benefits without inadvertently doing something fraudulent. I guess that is for posting elsewhere, but I’m finding it incredibly difficult to understand/wrap my head around what constitutes fraud and what is okay. Feels like a math (word) problem I don’t get!

    Thanks for all your help!

    • :) Equilibrist, you’re so welcome! Here’s three of many posts I’ve written about setting fees for your clinical practice.
      *How Do You Know if Your Clinical Fees are Set Just Right? Tighten the Screw!
      * How Mental Health Professionals Can Justify Their Fees
      * Know Your Worth – Setting Your Fees for Private Practice

      What I think I hear you saying, Equilibrist, is that you are not sure what value you bring to your clients – thus the ambivalence in setting the correct fee. It doesn’t really matter, does it, what your analyst and I think about your fees. Until you understand the value of working with you, your clients will pick up on the ambivalence you feel and they, too, are likely to feel ambivalent about your fee. (I’ve learned that it’s more useful for me to acknowledge a therapist’s ambivalence and help them get clear about their real value to their clients than it is for me to just say “Go ahead! Raise your fees!”)

      I’m not sure I’m understanding your questions about fraud and out-of-network benefits. Use the search box (upper left sidebar) and look for terms like “managed care” or “insurance.” Perhaps some of those posts will answer your questions. If not, feel free to ask again. Maybe one of us that hangs out here can help you answer them!

  19. I thought it would be nice to have a comment from a patient’s perspective on here.

    My wife is seeing a psychiatrist, and as part of the process I had an appointment to give my perspective. The appointment was during working hours, and unfortunately my work load was very high for the particular day of my appointment. I phoned in to cancel (on the answering machine), and I figured I would hear of some type of cancellation charge because it was short notice.

    Typically, all cancellation charges I have experienced in the past with other doctors were in the $20-25 range. I checked my bank statement and was shocked to see $200 taken out of my account just because she had access to my card from paying a co-payment. Now, she no longer receives any money from us because we moved to a new doctor who has more relaxed policies. This doctor was so greedy for her money that she is ending up losing money because she is losing clients.

    I could have accepted a $50 charge, but charging the full $200 fee is ridiculous! Even airlines who are famous for ridiculous change fees do not charge $200. I know that time is money, but when you are not doing your actual job that allows you to charge your full fee, you shouldn’t be justified in charging your full session fee. Additionally, insurance pays for my wife’s sessions, and we only pay a co-pay. Because insurance doesn’t pay for cancellation fees we got hit with a good sized bill here against our will. I never authorized this charge, and I am disputing it with my bank. It is one thing to bill me, but it is entirely a different thing to just take it upon yourself to charge my card when I never authorized it, or was aware of it myself.

    I feel violated. I am not a criminal or shady person at all, but I do feel that this is not right, and that I am rendered helpless in this situation. If the dispute does not work I may have to make it cost her $200 or something somehow. You know what they say about kharma….

    • Hi, Mark! I’m so glad you dropped in today to share some really important points from a client’s perspective. Thank you!

      If your wife did not receive both written and oral notice that she would be charged for non-emergency cancellations on short notice, you absolutely should not be required to pay such a fee. Licensed therapists are ethically required to disclose all potential charges to clients and are supposed to present that information in writing (typically in the form of a disclosure statement) and orally (commonly referred to as part of providing informed consent).

      If the psychiatrist did appropriately inform your wife of such a fee, I do think that s/he should be able to charge whatever she chooses. What clients often fail to understand is that a mental health professional started preparing for that session long before that actual scheduled hour and also has responsibilities to his client during that hour (whether the client actually shows or not) and has responsibilities to that same client even after that scheduled appointment time has come and gone. I agree it is a hefty fee but presumably her psychiatrist was carrying through on his / her end of their agreed contract.

      However, Mark, I also want to note that life happens and “emergencies” are defined differently by different professionals. You and your wife were wise to check out her new doctor’s policies and what is and isn’t acceptable concerning cancellations. Although my cancellation policy states that I require 24 hours notice unless there is illness or an emergency to avoid payment of my full fee, I am quite generous in my interpretation of “emergency.” As long as my clients do not present a pattern of late cancellations, I include everything from “having to work late” to childcare issues as qualifying as those “emergencies.”

      I hope that both you and your wife have found a new doctor that “fit” and meets your needs. I welcome you voice here and appreciate your expanding the conversation here. I hope you will feel free to drop back in often to share your thoughts.

  20. For what it’s worth, what about the other side of the coin???

    As a client, in the last 6 months my therapist has double-booked me twice (and I had to leave both times) and she did not turn up once (with no attempt to contact me, only responding after I sent an email and sms 24 hours later. Then she apologising for having a flat tyre and not having my phone number on her). Is it too much to expect that she would have at least attempted to call me the next day, instead of wait until I contact her the next evening?

    My therapist expect full payment if I do not show. So it makes no difference in your life one bit. In fact, she’s better off because she gets a paid hour to catch up on her phone calls and emails. What do I get when my therapist double-books me? I get sent home, incredibly angry and feeling let down and betrayed. I cry all evening because after a huge day at work it’s already taken every ounce of energy I have left to keep my commitment to seek the help that I need. To then spend an hour in peak hour traffic for nothing when I could have been home resting, even makes me more angry. I am in trauma therapy and I it is the toughest thing I have ever done in my life. But it is 100 times tougher to experience being let down by my therapist. It happened tonight and all I can think of is, “three strikes and you’re out”. I am so angry I will never go back.

    • Hi, Janine! I’m so glad that you took the time to share this side of the coin with me and my readers! And, I’m so glad that you are questioning the fairness of your therapist’s behavior and choices. This is such an important topic that I would like to respond to this more fully in a blog post. I’m wondering if you would mind if I did so and also if you would like me to share your name – just “Janine” in that post?

      I suspect that you will find a lot of therapists in this community are supporting you in moving on to a new therapist that can actually respect / value your time and begin to earn your trust. Please let me know your thoughts.

    • I agree Janine, it’s a two way street. Both parties have obligations as well as boundaries. Doesn’t sound like this is the therapist for you.

    • Hi, Janine! I just realized that you don’t have an gravatar set up. If you would like a little image of you to pop up when you leave comments here or elsewhere, you can get instructions right here. They’re really easy and help us feel like we actually know you a little better.

  21. This is the first time I post. However, I have learned so much from all the posts on this website. Tamara, thank you for making this available.

    I am unable to charge for “no shows” or “late cancellations”. I work for a rural health clinic and a majority of my clients have medicaid. We are not allowed to bill medicaid clients for anything! This blows my mind. Therefore, they can’t be charged for a no show. Most of my clients schedule several appointments ahead of time. My current policy is two no shows and further appointment slots will not be held for them. If they wish to schedule another appointment they will have to wait.

    Suggestions? The one month I implemented the no show fee, my compliance rate increased significantly. However, I am no longer able to do this and feel there needs to be accountability.

    Thank you,
    Michele

    • Hi, Michele! Welcome to the table! Happy to have your voice here and so tickled to know that you are finding the information and support here to be useful!

      My practice is a cash-only practice so I’m hoping some of the Medicaid-savvy therapists will be joining in on this conversation. Do you work independently or own this clinic? Or is this a place that you are employed? The answer to those questions may dictate in part what you are able to do with clients who fail to show for appointments. Who is it that says you are not allowed to bill a Medicaid client for anything – is that the agency’s policy or the US Government’s policy. Those are important distinctions.

      I would like to note though that either way, there should be consequences for choices the client makes. When I first begin working with a client I really lean into the mutuality of our relationship i.e. the expectations each of us has and the responsibilities that each of us has to ourselves and each other. When I have a client who does not appear able to value and protect our allotted time – by “forgetting” an appointment, coming late, or repeatedly going over the scheduled time – I revisit that concept of mutuality and the expectations that each of us has. Sometimes I find that my client was frustrated with our work or angry with me and didn’t know a better way to express it than to simply pull away by “forgetting.” In those situations, I have often been able to turn the tide buy having candid conversations in which we both put our frustrations and irritations out for re-examination. However, if I have failed to read (or misread) ego strength or the solidity of our relationship, it is not always a productive conversation to have.

      I also like your approach to use scheduling as a way to maximize attendance. A variation on that might be to relegate repeat offenders to seeing you in non-prime hours of operation. Anyone else able to contribute possible solutions to Michele’s dilemma?

      • equilibrist says:

        I used to work in an agency whose primary client base was Medicaid patients. It is my understanding that Medicaid patients cannot legally be held responsible for paying for sessions they do not attend–at least this was the way it was always presented to us as therapists in the clinic. Our only recourse was to have a policy of “three missed appointments and we have to close your case.” It was often very frustrating to work with these clients, as there were absolutely no consequences we could put in place other than the threat of denying them treatment. I feel it’s very hard to engage clients if there’s nothing at stake and no investment on their part. I don’t mean to deny the very real problems and hardships these clients often faced, including difficulties sometimes in getting to their appointments (we provided public transportation vouchers for them to get home, but if they had no money to get to our clinic, they were out of luck). But still it seems to me to be a very difficult situation.

        I’m not sure what the difference is between Medicaid and other insurance, because we were sometimes able to charge the client for missed appointments if they were using private insurance. But not with Medicaid.

        • Equillibrist, thank you for sharing your experience. It’s true. When working with managed care companies – other than Medicaid – it is common practice to charge the client (not the insurance company) for missed appointments.

  22. I’m not a therapist so am writing as a client. My best therapist was very reasonable about cancellations and in return I was always sure to give adequate notice, barring emergencies. I once showed up for an 8am appointment and he wasn’t there, he’d just forgotten. He very kindly gave me a free session to make up for his lapse. He also, to make up for my inconvenience, offered to meet at a neutral site of my choice. (This seems odd to me now, but it may have been at a time when he was between offices.) he came to my workplace on a Saturday and we had a very productive session on clutter and disorganization.

    In contrast, another therapist cancelled at short notice via my cellphone, which i rarely use, and didn’t confirm that i’d gotten the message. I made the fairly long trip to her office and discovered from another therapist that she wasn’t there. No apology forthcoming from her.

    Treating this therapeutic frame stuff as considerately as possible is very important for having a good therapeutic alliance.

    • Sjw, thank you so much for taking the time to share these experiences from a client’s point of view. It’s so easy as a mental health professional to unintentionally insulate ourselves with the advice and experiences of other therapists and fail to consider how personal it can feel to be “forgotten” or taken for granted. Your first example is my policy, too. I’ve double-booked clients on at least a couple of occasions over the last 30 years. When I make the mistake, I give a free session, too. “What’s good for the goose is good for the gander,” right? It just seems like the fair thing to do. I love that you actually remember not only how your therapist attempted to “make it right” but also what you actually worked on. As therapists, we never really know what sticks and is memorable to our clients.

      Your second example really underscores why therapists need to think through their cancellation policies ahead of time lest they risk hurting or offending (and possibly losing) clients. Your reference to the therapeutic frame and alliance is right on target, too!

  23. Considered says:

    I have an interesting situation I would welcome opinions on. I’m a client.

    Context/background

    I have been seeing a female therapist on and off for 5 or so years. I sought therapy for a number of issues, predominantly stemming regarding control/manipulation regarding my mother. It is also relevant that I previously saw a male therapist who breached the boundaries of our relationship by sending (albeit jokingly) emails about sex/genitalia and i felt it was highly inappropriate – i stopped seeing him and told my therapist about this in our first meeting – boundaries both from my relationship with my mother and my previous therapist have been a very strong issue.

    My therapists’ cancellation policy is absolute – there is no minimum or maximum cancellation time – you will be offered an alternative appointment(s) and if you cannot make any of the re-offered appointments, you are liable, irrespective of any circumstances whatsoever.

    I recently cancelled 2 appointments when my mother had a brain haemorrhage. The first session was cancelled by voicemail (to which she then left a message saying that appointment time would be kept free or i could call to re-arrange, despite my cancellation message saying i would be in touch ‘whenever’) and the second was cancelled on the day by text, stating that care had to be withdrawn and my mum was going to die that die, that i didn’t want further sessions and would be in touch when/if i did).

    4 weeks after mum died, i got in touch and arranged a session last week. At the end of the session, i was told that she wanted to charge for both sessions. I said i felt that was ‘harsh’ and wouldn’t pay – she said it was for my benefit, and that we should discuss at my next session – which was tonight.

    I have no reason to doubt the integrity of my therapist. She has helped me make significant progress, and for 4 months when my financial circumstances changed dramatically financially, she let me pay about 50% of the usual rate. My issue with paying is not about the money, i have no evidence this is about greed, but i do not feel the rules are realistic nor, if push came to shove, legally enforceable. Overall, we spent the whole of tonight discussing it, i still refuse to pay, she does not accept it.

    My points were as follows.

    1. I did not realise, whilst i was given the terms in writing, that in no circumstances was cancellation possible. I would never had agreed to that. I also feel there should be something in the terms that specifically states ‘no circumstances whatsoever’ – i feel it was reasonable for me to assume that emergencies outside my control would not attract a cancellation fee.

    2. I was a contract lawyer for 4 years – under english law, no court would enforce an ‘unconscionable bargain’, and a situation where one party would be liable where that party cannot perform a contract due to circumstances beyond their control is an unconscionable bargain – the contract would be void, or at least that clause would.

    3. Leaving aside the law, practical reality trumps psychoanalytic theory and must protect both parties fairly. There is no gain for me therapeutic or otherwise in paying where there are circumstances beyond my control. I learn nothing about myself (other than i should always read the small-print) as my behaviour wasn’t a factor in why i didnt go. I absolutely understand that loose or flexibile terms would be open to abuse and that the therapist isn’t my friend or mother – it is a professional relationship and time is money – i have paid late fees on 2 or 3 occasions for no shows, minor illness and choosing a social occasion over therapy – not too bad for a 5 year relationship. She said part of the lesson is that things happen in life that are unfair, and that she should not be made liable for my misfortune, as it is not her fault either (i accept that).

    4. In the UK, we have the ‘rule of law’, stating that no one (monarchs, the police etc) is above the law. If she seeks to enforce a contract that no court would uphold, then this is stating therapists are above the law – they are not. The nature and benefit of the therapist/client relationship, transferential issues does not provide special exemption from the law. The law is the law and i dont necessarily blame my therapist for this, it is the professional body who have told her these are acceptable guidelines (unless she has breached these and done her own thing). The governing body is wrong if it thinks these are agreements are enforceable in cases where contracts are ‘frustrated’ by circumstances.

    5. My issues with her reasoning are

    5.1 on the point of ‘why should she suffer for my misfortune’, well, why should i suffer for hers? It is unfortunate if therapists cannot get insurance for emergency cancellations, but I should not suffer for it. I said i felt it is unrealistic and that this contract isn’t balanced – i gave the example of making the reason for the cancellation less emotive eg what i got stranded in a foreign country due to a plane strike, to which she said i would be liable as there is ‘no scale of reasons for a cancellation’- you make it or youre liable. I then said, for example, if there was an agreement between two parties to manufacture 10,000 cds on a certain date, and the party who was making them’s factory was hit by lightening the day before, they would not owe damages for not delivering them on time. She agreed and said it would an insurable event – i agree, but see above on insurance and it not being my fault she cant get any, or has chosen not to.

    What is also frustrating is that she seeks to impute therapeutic meaning into this objection, saying it is all about my mum and loss – she wont listen to me adult to adult and understand this is not an emotional issue – the contract is unethical, unenforceable and unrealistic. She also said that i had a ‘choice’, and that i chose not to come to therapy on those occasions. Im sorry, but where’s the humanity? I am the next of kin and had to be there at all times to give consent to medical treatment, let alone the emotional reasons for not being there! I had no choice at all.

    I could go on, but that is the gist of it. I think unfortunately it is going to end our relationship – more than anything, if i pay, it means i agree to the premise and agree to be bound by it going forward, and at the time of writing, i dont think i do. There may also be issues in the way the debate ensued about her feeling she would lose positive influence over me if she concedes, and also that there were other cases with other clients in which she possibly shouldn’t have asked for payment. There is an obvious inconsistency in her well meaning logic and lesson – if she shouldnt suffer for my misfortune, why halve her rate for 4 months when my financial circumstances changed – she could have seen someone for twice the price. The message isn’t consistent and has now made me ponder her motives for keeping me on – is there a control issue for her (obviously that would be transferiental, but that doesn’t mean i can’t feel controlled if someone is trying to control me). Something isn’t right.

    This does not feel abusive and i believe this is someone who believes ardently in her practice and that it is the right thing to do (but apparently intellectulisation and rationalisation are two key defences i use to distance myself from emotion, so maybe i do feel abused – and perhaps rightly so! It seems to me they may be her defences too).

    I think has been a great therapist, but if she cant change her mind about things and is that hard-lined, will she notice or accept changes in me that no longer fit the model she has for me?

    Therapy is a noble profession – but there is nothing noble in fining your clients in instances of genuine emergency because you cannot get insurance. If she cannot accept that, and if life is about choice, then either she needs to change her policies or choose another profession, or i need to accept her policy or find a new therapist – and i know what i choose.

    I hope this ‘client side’ view is useful, and i would welcome any thoughts at all.

    • Considered, thank you for taking time to so thoughtfully share your situation with your therapist. It is invaluable for therapists to understand how / where their clients are coming from and your story is certainly an interesting one. I’m so sorry for the loss of your mum. I think that for most of us, your choice to spend time attending to her last needs and the needs of her estate would have taken priority over an appointment with our therapists.

      I’m also in the United States and am not an attorney so can’t speak to the enforceability of your therapist’s policies or her personal or clinical motivations. However, I can say that when therapists are perceived by their clients as lacking humanity, their relationship and the work they are able to do together are compromised. It is entirely possible that each of you may have the best intentions possible . . . or not. And, in this situation you and your therapist have some work to do in rebuilding trust before you can move forward. I understand why you are considering moving on to a different therapist if you believe this is an irreconcilable difference. However, I do want to suggest that, assuming your therapist’s position is coming from good intentions with a healthy dose of self-awareness, you and she may very well still be able to work this out to your mutual benefit. If the latter appeals to you, you may want to consider engaging a third party to help you two navigate this little leg of your journey.

      Either way, I’m wishing you a gentle and productive journey. And, thank you, again, for reminding mental health professionals around the world that it requires careful thought and clinical skills to create policies that are fair and clinically useful to our clients.

  24. Hi,
    This is a current tale from the other side involving two family members.
    My son was seen at a group practice for a traumatic experiance last year.
    Our family has excellent health coverage. We have a $20 co-pay. This is a
    good thing.

    So I read through the policy and it stated there is a $100 missed
    appointment fee for not giving 24 hour notice. OK, so I understand why
    there is a policy. People in these situations cancel far more frequently than
    other medical appointments. But the policy raises a Big Red Flag for me
    as my son has an inborn metabolic disorder. If he vomits we go to the ER.
    That’s it the day is over. We are now on sick time. So if the appointment is
    at 4pm but we are at the ER at 1pm there is no way to give 24 hour notice.
    By the way, this is all very well documented by the treating doctor’s office
    and hospital.

    Well, I explain to the receptionist about our situation.
    She said in the case of my son being ill they would waive the fee.
    Just in case, I cleared this with the doc treating my son. Again the would be waived.
    By the way, it was up to doctor to set the fee not the business office.

    This when well my son was treated for 8 months and then went off
    to University. He is doing quite well. He did not miss any appointments. I’d like
    to add that as a family we understand that if appointments are missed you don’t get
    better.

    This is where it all goes south. My husband suffers from anxiety and depression.
    He is being seen by a social worker in the same office since last April. He has not
    missed nor been late for an appointment. He is also a Federal employee.

    About a month ago, he was what they call ‘forced’ into work. For the uneducated,
    this means if the employee leaves work they are considered AWOL and will be
    immeadiatly terminated. 26 years of employment down the drain.

    My spouse called the office to cancel as soon as he knew it was less than
    24 hours. The social worker said it was up to the business office to waive
    the fee. Upon making inquires, it was up to the social worker to enforce
    the policy. But to get documentation from the employer.

    The documentation explaining the reason for missing the appointment
    was given to the social worker who clearly was caught off guard and still
    stating it was up to the business office. Oh, did I mention it was on Federal
    Letterhead? I just recived a bill which lowered the missed appointment fee
    to $ 50.

    Losing one’s employment is not a true emergency? My husband did make his
    appointment which was in the evening. All appointments in the future will
    have to be so since there is way to know if he will have a schduled day off in
    future.

    As for the relationship with the social worker which the trust has been breached
    because of her inability to be honest and accept her responsibility in enforcing
    and collecting the fee we’ll be booking an appointment with someone who is more
    mature and professional.

    In closing, it seems really sad that a so called medical professional
    would breach client trust over a lousy 50 dollars.
    Any thoughts?

    • Hi, Willybeth! I love that you’ve taken the time to share these two stories! They are excellent teaching tools for health care professionals. As you were relating the first story about your son’s situation, I was already thinking that surely the health care professional ended up doing the right thing! After all, the goal of a cancellation policy should not be to punish a client for something that is unavoidable or for doing something that is necessary for his / her own health! I’m glad to hear that worked out well for your family and that your son is off doing his own thing at the university!

      In the second scenario, I’m right there with you – it really is sad that a medical professional is unable to address these money issues head on. It speaks, I think, to the discomfort that many of us have struggled with related to money. Your experience is not all that uncommon. I’ve met many therapists who were so uncomfortable discussing money matters with their clients that the went broke or passed the difficult conversations on to office staff rather than dealing with their own issues. It is, of course, the therapists job always to resolve these issues (with their own therapist, if necessary) rather than denying them and then having the client deal with the consequences of that denial. Certainly a business owner has the choice to set up whatever financial policy s/he chooses; however, it is an ethical (and most likely legal) requirement that the therapist also clearly disclose the nature of that policy. I’m not sure that happened in your situation – otherwise, you would not have been surprised to receive a bill for $50. That, to me, is the red flag.

      If your husband and the social worker cannot repair the breach of trust, then I’m afraid he may indeed fair better with another therapist; however, many times, if you are willing to have those difficult conversations, you will find that there is actually a pathway back to building trust. Either way, wishing you and your family best wishes!

      • equilibrist says:

        This is an interesting situation. I have a different thought about the $50 charge for the missed session in the case of your husband being called into work. Of course, all of this depends on the fee and cancellation policy having been made clear to you at the beginning of treatment. If they were, however, it seems to me that the therapist is being quite reasonable and giving you a break by “splitting the difference” and charging you $50 for the missed session. That way, each party has to take part of the hit and make a sacrifice. Each pays half, though the therapist is actually under no obligation to do so–it is indeed sacrificed income for the therapist. The situation is not the fault of the patient, but it is also not the responsibility of the therapist–who is, after all, a professional who has to make a living–to subsidize unfortunate events that occur in the patient’s life. If we did that, we would soon be out of business!

        I have heard of therapists’ splitting the difference like this, and to me it seems fair to all involved, though of course I would hope that it could be discussed in session and the rationale for it made explicit to the patient.

        • Equilibrist, it’s good to have you back here again! And, as I think you are pointing out, this really does boil down to it being a therapist’s job to have a clear policy on cancellations and an equally clear understanding with a client just exactly what that policy and agreement are. People laugh at me because – after 30 years in the field – my disclosure statement is . . . rather lengthy. But, between me spelling everything out in detail and following that up with a clear conversation at the first appointment . . . I’ve never had a client come back and say “I didn’t understand . . . . ” They may forget but they never misunderstand my policies.

          • Equilibrist says:

            Hi Tamara–I agree wih you that it’s important for the therapist to be clear both with the patient and with him/herself about cancellation policies–but I’m not sure I agree that a client will always understand, no matter how clear we try to make ourselves. If psychoanalytic training has taught me anything, it is that people can create out of any situation whatever “understanding” most suits their psychic needs. And If they “forget,” that is also meaningful. Of course, that is all further material to be analyzed!

            • Equilibrist, I agree 100% and it’s still our ethical responsibility to be clear and understood. It’s way too easy, I think, for us to not own our own discomfort with money, confrontation, or whatever and then attribute that to our client’s issues. If the disclosure statement is clear . . . if the informed consent process is complete . . . and both are signed off on by all parties, then I think it’s fair to declare “I did my part.”

              Related to that in my own history . . . . As a new professional who started off working in addictions, I (and too many of my peers) were too quick to declare all too often that our clients were “resistant.” In hindsight, what I believe now is that “resistance” in clients is more accurately described as “therapists asking clients to move too quickly or take too big of a step forward.” And, clients struggling with their addictions are the perfect example of this . . . . Getting him / her to admit to being an alcoholic or being an addict before they even acknowledge that they are repeatedly incurring negative consequences for their choice to use a particular substance seems almost illogical. I see why the language of “resistance” may be used but a more useful reframe (if the goal is to help the client move forward) might be for therapists acknowledge that their jobs are to make therapy “safe enough” and the steps “small enough” for a client to take his / her “next steps.”

        • Glad to hear your response.
          First thing to point out he was not called into work.
          He was at work. Hence, it was a direct order. To disobey such order is to be automatically
          terminated. Let’s make that clear. The social worker should have been quite clear on this.
          It’s part of why he was there.
          Two it was she tried to pass the buck off on the business office instead of setting the boundaries
          with a clear cut policy set by her. Hiding behind the business office isn’t being honest. That shows issues on her part. Not something that builds confidence for the customer. If as a family we showed bad faith by missing or being late for appointments I could understand. But we had not.
          Splitting the difference is a great idea if both parties are aware of such policy.
          How about the times she has cut the session short by 10 -15 minutes? Do patients get a refund for that time? Add that up and she would owe us money.
          This is not so much about the $50 it’s about how to run a business 101.
          The social worker could still have a client and good references but now she has no client is considered unprofessional at best but she has $50 in her pocket.
          Last time I checked this wasn’t how to succeed in business.
          I agree with the be clear and direct not just in business but in life as a whole.
          The world would be a much better place.

          • YIKES! What caught my attention here is “cutting the session short by 10-15 minutes. Really? That happens? Repeatedly? OK, that’s a problem. For the record, therapists should start and end sessions on time. If there is a rare need to vary from that, then that’s a conversation that needs to be had with the client and a mutually agreed upon resolution. If I have a need to end early . . . and I’m not really sure what would require that . . . I would offer to tag that time on to the next session. And, if I see a need to extend a session with a client for some clinical reason . . . I would pause in our work long enough to see if this is acceptable to the client.

            • Amen, to that!
              The reason I mentioned it at all was about the ethics of not just being self employed
              but as a business owner in general. ( And yes, it is a double Yikes!
              There is a reason to no longer see this particular social worker. Several, in fact.)
              But that has become quite clear.

              This is a comparison : I own rental properties with leases. The ‘ policy’ is stated very clearly as to the acceptable/nonacceptable. In English & Spanish. At times, we have to go over these terms more than once. They forget they didn’t read the fine print,etc.
              This is part of any business. And yes they all do the ‘let me show you my map of the
              Universe’ reality. You get the no matter what your business is- Social Work, Landlord, Day Care Owner,etc.
              Sometimes you cut a customer some slack because the situation warrents it. That’s part of running a great business. I get that – you seem to get it to.

              Quite frankly, I’m glad to have this discussion with you. This all started out with a no-show policy payment. Which led to a rather honest discussion about his sessions.
              That’s when it came out that the sessions were being cut short. He is currently searching for someone which should be resolved this week. Interestingly, enough it turns out she (social worker ) is quite young and has only been in practice a few years. Which explains quite a bit. If she is indeed splitting the fee that’s great. But we don’t know this because she didn’t communicate it.

              If I may be so bold as to suggest – that many self employed people take basic business classes to better model their business on.
              As referred to in my first post there a three people in my household with an inborn metabolic disorder. As a result, many hours are spent with insurance, MD & Hospital in patient & out policies. Adding to that our insurance is federal so I have to deal with various States depending on the service /product. As of January, we have reached into the catastrophic protection for fiscal 14.

              You would be shocked at some of the glaring errors made by by the above businesses during the end of the year audit. Most are settled very rapidly. Every once in awhile it becomes ugly. But it’s business.

              Not sure that this has helped or hindered anyone. It’s the voice from the peanut gallery. As for my spouse’s situation – he’ll be better off with someone else.
              The Social worker will be mailed a letter as to what went wrong and why.
              It’s not nice to leave someone dangling. But there is no point in making an appointment with her to explain that she needs to be upfront about money issues.
              ( nobodies favorite topic, unless they won the lottery.) Her payment has been made.
              He’ll be discussing policy and length of appointments in the first visit with his new social worker. But thank you for your Yikes! and clear cut honesty in your answers.
              Really appreciate it. It’s been wonderful!
              Take care, Willybeth

              • Willybeth, it’s my honor to have your voice here. All therapists make mistakes . . . and that includes errors in judgement. Private Practice from the Inside Out is where mental health and allied health professionals can learn from each other and clients, too, as we strive to build healthy practices and strong businesses in which both therapists and clients can thrive. I often tell new therapists that, in large part, we earn our fees for making judgement calls . . . moment by moment all day long. Ideally, we are helpful more often than we are not but every therapist needs to be aware of the weight of trust that our clients place in us and the consequence of disillusioning them. Your and I wish you and your family the best on your journey. Your willingness to share your family’s experience underscores for each of us how easily a professional relationship can be damaged.

                Wishing you and your family all the best on your journey . . . and wishing your husband’s soon-to-be-former therapist the wisdom to learn from a client who is willing to send a letter explaining “what went wrong.”

      • Thanks for a rapid response.
        Unfortunately, my spouse will find someone else.
        What I failed to disclose was the fact the both my son and
        husband were seen by two different people in the same practice.
        So the policy is the same across the board. Both of us spoke to the
        Business Office on different occasions. The answer was the same
        it’s up to the social worker and yes the letter from his place of employment
        should have been accepted.

        As for the social worker, this may sound harsh but it not out
        responsability to educate her regarding policy at our expense.
        Which would mean wasting valuable time in a therapy session that could
        be used in a more constructive manner. I say this as a matter of the patients
        is valuable as well. As stated in earlier post it’s all about boundaries.

        As a side bar, this is not so much about the 50 dollars.
        We own rental rental property. Trying losing 6 months rent.
        It’s about the ethics involved.

        Thanks for hearing me. Have great weekend!
        Willybeth

        • Willybeth, thanks for staying connected to this discussion and dropping back in. You are exactly right about it not being your responsibility to educate your health care professional. I’m not understanding your comparison about your rental property but I do recognize that there is an ethical component to all of this.

  25. I believe that as a Therapist who are treating mentally ill charging for no show fees when there are mental and health issues that cause the situation is unethical. Each one of you should look at the code of ethics. I can’t believe that you don’t fill your time with phone calls, billing, and chart requirements. I have a daughter who has a sleep disorder, anxiety and eating disorder. I believe this is totally wrong under the specific circumstances.

    I am not talking about a $50 fee, I’m talking about a $135 fee. I am a business consultant and treating patients across the board, is not acceptable and I will never recommend this particular therapist, in fact I will let people know not to even consider this therapist.

  26. If you are an independent contractor within a private practice, who does the no show fee go to? The practice, independent contracted therapist, or split?

    • Hi!, Amber! And, welcome to Private Practice from the Inside Out! That’s a great question and the answer is that it’s entirely up to you – and what you were able to negotiate when you entered into your contract. I’ve seen all three done. Just make sure you get it in writing!

  27. I need help with a therapist charging a family member after they had canceled their appt 48 hours in advance. The therapist said she required 72-hours in advance. At the time the appt was canceled the therapist did not let my family member know she would still charge, she just charged her credit card anyway. Without even clarifying the charge or policy! Are there any legal limits of days for cancellation policies that you know about? Any advice in this situation would be so much appreciated.

    • Hi, Gina. I’m so sorry your family member is in this situation with her therapist. I would recommend that she (1) review the disclosure statement that she originally signed with her therapist, (2) talk with her therapist at her next appointment about the misunderstanding or discrepancy, and (3) ask for the fee to be waived.

      If she is unable to resolve this situation with her therapist, she may be able to file complaints with the Better Business Bureau, the therapist’s licensing board, and possibly with any professional association that the therapist belongs to. I do not know of any legal limits of days for cancellation policies. However, I am not an attorney. An attorney in your jurisdiction may know the answer to this question and may offer him / her different legal options.

      Best wishes to your family member!

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