by Steven Walfish, Ph.D. - The Practice Institute

One of the reasons it takes most people a year or two to build a practice with a full case load is because successful clinicians receive at least 25% (if not more) of their new clients based on a referral from a former client.  That is, Joan tells Barbara that she has been in counseling with you and that you were helpful for treating her anxiety. As her friend Barbara also has anxiety Joan suggests to her that she call you for counseling as well.

Similarly, Bob was having difficulty with depression and upon referral from his physician, he sought out counseling with you and his depression lifted.  He knows that his cousin Derek has struggled with depression for a long time and they get to talking at a family gathering. Bob tells of his experience with you as a counselor, that his life is now so much better, so he suggests to Derek that he gives you a call.

This is one way practices are built and sustained. Because it takes a while to build up a following, this 25% takes a while to have a meaningful impact on your referral flow since new clinicians do not have enough former clients to make these referrals.  Jeff Barnett and I in our book Financial Success in Mental Health Practice label these satisfied customers (yes, our clients are our customers!) who tell other people about the quality of our services as “Apostles.” Simply put:

The more Apostles that we have, the fuller our caseloads will be!

Some clients are secretive that they have been in counseling. Therefore, while they may be satisfied, even thrilled, about the work they did with you in counseling, Mum is the word!  As such, not all are going to spread the word about you and the high quality services that you provide.

But what if you have been in practice for a couple of years (or more) and find that you are not receiving at least 25% of your new clients from former clients? It may be time to do a self-assessment of both your customer service practices, and indeed the clinical care that you provide.

More than 90% of non-mental health businesses believe they provide superior customer service. However, when actual customers are surveyed only 8% believe they have received outstanding customer service. There is no reason to believe this is not true for mental health providers as well.

  • Do you have hours that are accessible for clients?
  • Do you return phone calls the same day they are received?
  • Do you provide office paperwork on your website or with permission email your forms to clients do they don’t have to arrive 15 minutes early for their first appointment?
  • Do you provide explicit driving or public transportation directions to your office?
  • Is your billing system and invoicing easy to understand?
  • Do you accept credit card payments? Do you provide complimentary coffee/tea/soft drinks for clients?
  • Do you fill out paperwork needed by the client for their insurance and not charge them an extra fee for doing so

These are but a few customer service practices that may optimize satisfaction with your professional services. If former clients are not referring to you, then it may be important to have an outside consultant do a review of your customer service practices.

Another possibility if you are not receiving at least 25% of your clients from former clients is a more difficult thing to consider. That is, you may not be as clinically effective as you think.  Most people believe they are good, if not excellent, clinicians.  However, mental health professionals are as susceptible as anyone else to self-assessment bias. A study that I published in 2012 with Brian McAllister, Paul O’Donnell and Michael Lambert found clinicians to:

  • overestimate their own abilities compared to other clinicians,
  • overestimate their percentage of clients who improved in counseling, and
  • underestimate the percentage of clients who deteriorated as a result of counseling

(if anyone would like a complimentary reprint copy of this paper write to me at While in general it may be helpful to measure client progress in counseling (see the work of Scott Miller), it may be especially important if you are not receiving referrals from former clients. You can set up a system to measure progress by session or to obtain client feedback once the course of counseling ends.

So, if you are receiving referrals from former clients you are likely providing high quality customer service and clinical care. If not, it is time to take stock of your practice. The importance of paying attention to this type of feedback cannot be underscored. It is essential to sustaining a full clinical practice.