The Intake

Insights for those starting, managing, and growing independent healthcare practices

Setting boundaries with mental health clients

Learn strategies for setting professional boundaries with your counseling clients to build a sustainable, ethical, and thriving private practice.

This post is a part of the What to Know Before Opening a Mental Health Practice series
setting boundaries with mental health clients

At a Glance

  • Setting clear boundaries with mental health clients is essential for maintaining a sustainable private practice, from establishing payment and cancellation policies to managing personal questions and treatment requests.
  • Common boundary challenges include requests for documentation, treating multiple family members, handling insurance changes, and maintaining appropriate limits in telehealth sessions.
  • While setting boundaries may feel uncomfortable, it actually improves client relationships, protects your practice financially, and models healthy relationship dynamics for clients.

Welcome to the "What to Know Before Opening a Mental Health Practice" series by Kristin Trick, MA, LPC-S, RPT. Drawing from a decade of diverse clinical experience spanning psychiatric hospitals, nonprofit agencies, and private practice, Trick shares the top 5 lessons she wishes she had known before becoming a solo practitioner. Packed with practical advice and insights from her journey, this series supports mental health professionals looking to establish a thriving and sustainable practice.

An instrumental skill for private practice owners is the maintenance of good boundaries with clients. The ability to establish healthy limits in counseling relationships is one we must cultivate, and no practice should be started without its mastery. 

Prior to beginning an independent practice, I had avoided saying “no” to clients and had become quite adept at it. Declining clients’ requests seemed contrary to my role as a professional helper; I was eager to please clients and thought that by doing so, I was providing excellent care. Now a business owner, though, I recognize that solid boundaries with clients are indispensable to sustaining a thriving counseling practice.

Free report

Boundaries in counseling

Since much of our role as counselors is rooted in helping clients, it can feel uncomfortable or even mean to set boundaries with them. Especially if a client’s background is riddled with relational hurt and pain, we can worry that not granting their desires will force them into a dark emotional place. Not only that, when we are the practice owner, we may fret that disappointing or frustrating a client will result in a loss of their business. 

This has not been my experience, however. Clear boundaries have actually improved my relationships with clients since they now know my limitations and expectations.

Counseling is interpersonal to its core, though, which means that boundaries are continuously being fleeced out between counselors and clients. These limits start with our first client contact, as we explain what services we can provide and how much they cost. They extend throughout treatment as we address challenges of the moment, including late cancellations or no-shows for appointments, declined credit card payments, and changes to insurance benefits. Simply put, boundary-setting in counseling occurs whenever we resist clients’ attempts to cross our personal or professional lines.

Though counselors are known for our nonjudgmental attitudes, the fact remains that we have much power in the counseling relationship. We evaluate clients to diagnose their problems and determine proper treatments, as well as collect their payments and maintain their medical records. 

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When clients ask personal questions

Clients are not oblivious to this power differential and oftentimes ask counselors personal questions in an attempt to level the playing field. They want to see us as fellow human beings in whom they can confidently confide.

Most personal questions clients ask are innocent and intended to improve their connection with us. Across different worksites, I have been asked the following questions and similar ones by clients on a fairly regular basis: 

  • Did you grow up here? 
  • Do you have children? 
  • What side of the city do you live on? 
  • Why did you choose to become a counselor? 

When simple questions such as these are asked, we can casually provide answers or use prompts to learn more about why our clients are interested.

When professional boundaries are pushed

On the other hand, professional boundaries can be pushed when clients make requests for their treatment that we are unprepared to meet. We may not have worked long enough with them to provide certain information or we may not agree with their perspective. 

For example, clients may ask us to write a formal letter that attests to their need for a support animal or their inability to serve jury duty. If we do not believe this level of intervention is warranted, we can passively yield to their requests or assertively explain our difference of opinion.  

I once met a client who demanded at the end of their intake appointment that I write their boss a letter excusing them indefinitely from their work responsibilities. Recognizing their plea as unrealistic, I declined by stating their symptoms appeared mild and that we needed to meet for more sessions if they did not feel prepared to return to work. 

The next day, I received Family and Medical Leave Act (FMLA) paperwork from my client’s spouse, who insisted that I submit the forms that day. My professional boundaries had been seriously overstepped as I realized my client had not accepted my initial answer and had maneuvered their spouse in an attempt to get what they wanted. This experience taught me that sometimes clients have ulterior motives for receiving counseling and to be watchful of their intentions, even more so as a practice owner.

Sometimes clients have ulterior motives for receiving counseling and to be watchful of their intentions, even more so as a practice owner.

Why good boundaries are essential

Plenty of counselors have opened their own practice only to close its doors prematurely. Poorly managed boundaries with clients tend to be a common thread. If you do not assert that clients pay for their sessions promptly, for instance, you risk a loss of income if those clients do not make payments after you have delivered services. If you do not check in with clients about changes to their insurance coverage, you open yourself up to denied claims and write-offs.

Numerous opportunities to set forth good boundaries for your practice occur during the first session. Within this initial meeting, you can clarify details with your client about your attendance policy, hours of availability, and billing process. Besides verbally reviewing this information, you should also formally document such items on your intake forms, which need to include room for your client to sign their agreement.

Have credit cards on file

In my own practice, I require new clients to leave a credit card on file, which I can charge at the end of their sessions for the appropriate amount. Knowing all too well the financial crush that occurs when clients miss their appointments without notice, I now include a Credit Card Authorization Form in my intake paperwork. 

This document plainly outlines the times when a client’s credit card will be charged (copay, co-insurance, deductible payment, late cancellation, and no-show) and includes a client signature line. Since incorporating this policy, I rarely encounter outstanding balances on my clients’ accounts.

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Balance work and home life

Good boundaries with clients contribute to a healthy work and home life balance, too. As counselors, it can seem that we are ceaselessly giving of ourselves. While the majority of us joined this profession because we care greatly for others, we can easily become jaded and disheartened if we do not honor our own limitations. 

Owners of private practices juggle their personal and professional commitments with their home and personal lives exceedingly more than other counselors. While we want to enjoy the freedom accompanying entrepreneurship, we battle the daily temptation to overwork since the business is bound to our name.

Clear expectations and efficient follow-through with clients will help you maintain control of your practice. You can make thoughtful, well-informed responses as opposed to hasty, emotionally driven reactions. 

While we want to enjoy the freedom accompanying entrepreneurship, we battle the daily temptation to overwork since the business is bound to our name.

For example, instead of waiting impatiently for your last client of the day to appear when they are already 15 minutes late, call them to offer a phone session or email them a missed-appointment invoice. Rather than using your lunch hour to complete Family and Medical Leave of Absence (FMLA) documents, advise your client that you will finish them during their next appointment in order to clarify details. When working with minors who are part of an Individualized Education Program (IEP), schedule a parent-only session in which you compile your recommendation letter.

Setting boundaries in the counseling relationship can be a tremendous gift to our clients. Many of the individuals seeking our help have never been taught how healthy relationships work. This shortfall hinders their relationships with family members, friends, and coworkers, along with their interactions with us. Counselors set the tone for professional relationships as we communicate to our clients what is okay and not okay during our work together.

Comply with regulations

A common dilemma I have encountered is my clients’ requests that we continue meeting remotely after their move to a new state. This proposition can seem very agreeable when I enjoy working with them or need the additional income. However, current counseling regulations restrict our practice to only those states with which we have a license. 

Furthermore, legal business standards and insurance policies limit our services to states in which we are formally recognized. Though it has felt displeasing to end my clients’ treatment when they move out of state, I have peace of mind knowing that my business is operating honestly.

Counseling scenarios to consider

The better prepared we are to implement clear boundaries with clients, the more confident we will be when those occasions present themselves. As you make plans for opening your practice, conduct a self-assessment to identify any topics or situations that would discompose you if they occurred in your workplace. 

Not to be undervalued, the very act of thinking ahead and developing strong speaking points can help you feel at ease. The following scenarios are ones I have encountered throughout my career and include tips on how to respond with poise.

Conduct a self-assessment to identify any topics or situations that would discompose you if they occurred in your workplace. 

Client requests for you to meet with their spouse or child separately 

Scenario 1: Your long-term client requests that you begin meeting with their spouse or child individually while you also continue working with them. 

This inquiry can be flattering since it appears that your client is supremely impressed with treatment. It may seem to be the perfect solution, too, if the client’s troubles are entrenched in family dysfunction. 

Proceed with caution when addressing this request, though, since your acceptance or rejection will impact your client’s attitude toward their personal treatment. Typically, I limit my work to no more than 2 individuals per family and only accept the second client once the first has sustained significant progress. Specifically, I tend to work with a child or adolescent first, then open individual treatment for their parent after a period of 3-6 months.

Client requests to keep meeting after switching health insurance plans

Scenario 2: Your client switches their health insurance plan to one you do not accept but still wants to continue treatment with you. 

Clients’ transitions to new healthcare coverage (or none at all) can abruptly halt counseling since the original payment arrangements are no longer valid. Stay updated if you know this is a possibility by consistently asking your client about changes to their insurance benefits and clarifying a definite end date for their plan’s payments. Doing so will allow both of you to prioritize essential work during the final covered sessions you have together. 

Clarify to your client that once their current plan ends, they will need to continue counseling in a different manner. They may proceed with you using a self-pay rate, accept the responsibility of submitting out-of-network claims to their new provider, or restart counseling with a different provider who accepts their new insurance or can provide inexpensive out-of-pocket services.

Telehealth client joins from a public space

Scenario 3: Your telehealth client joins your video session from a public space. 

Due to their work schedules or household privacy concerns, virtual clients may announce at the start of their session that they are somewhere public. On occasion, telehealth clients have informed me that they are physically at a local park, school campus, or work conference room for our session. 

When this occurs, ask your client outright if they feel comfortable meeting you where they are. If the answer is “no,” direct them to move somewhere private while you wait for them. 

Inform your client that during the session, they will need to use a hand signal or code word to communicate with you if their space is compromised.

Inform your client that during the session, they will need to use a hand signal or code word to communicate with you if their space is compromised. In such situations, I usually advise clients to hold one hand up as a “stop sign,” which alerts me that I should not proceed with certain discussion topics. 

Check with your client to see if they have headphones available to ensure they are the only person who can hear your feedback. Most importantly, ask your client to tell you precisely where they are so you can send help if needed. If they do not know the street address, inquire about surrounding buildings, exit signs, or the distance from their home.

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Protecting your space

Despite its initial appearance, telling clients “no” is a vital skill for managing a successful practice. As you set good boundaries with your clients and encourage them to do the same, you will enjoy more aspects of counseling and business ownership. The precious time that could have been wasted in fretting over clients’ unrealistic requests or incessant demands can be swiftly invested in superior areas — namely, the financial planning side of your practice.

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Kristin Trick

Kristin Trick, MA, LPC-S, RPT is a therapist in private practice in El Paso, TX. She specializes in the treatment of post-traumatic stress and anxiety disorders, using evidence-based therapies including Play Therapy and Eye movement desensitization and reprocessing (EMDR). She has worked in the psychiatric hospital, non-profit agency, and private practice settings over the past 10 years. Kristin has conducted mental health presentations at the local, regional, and national levels. She enjoys running, cooking, and traveling.

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