Dr. Sharp: [00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
This episode is brought to you by PAR. PAR offers the RIAS-2 and RIST-2 remote, to remotely assess or screen clients for intelligence, and in-person e-Stimulus books for these two tests for in-person administration. Learn more at parinc.com.
Okay, everybody. Welcome back. Today’s episode is another new format for the podcast. I am really trying to experiment with a few different things here during this last quarter of 2020. So, please give me some feedback. Let me know how you liked that masterclass episode last time, and let me know what you think about this one too.
This time we’re going to be doing an on-air live coaching call with Dr. Kylee Miller. The idea here is that I meet with clinicians, we do coaching here on the podcast, and release it as a podcast episode. My hope is to cover issues that are relevant and current for many of you.
And to that end, what I am talking about today with Kylee is, how to be profitable your first year in private practice when you only have a part-time practice.
And we dig into questions like, can you even expect to be profitable that first year? If so, how do you balance overhead with the number of hours you need to work to come out in the black? We dig into her local insurance rates, private pay rates, and her overhead for testing including startup costs and monthly ongoing costs. We work through that math and figure out whether she can sustain a private practice and still come out in the black. So check this out. I would love for you, like I said, to give me any feedback and let me know whether you like this format.
Kudos to Kylee for being willing to engage in a little bit of an experiment and just go for it here on the recording. But this is super enjoyable for me. Like I said in the past, this is a big part of what I do. I love coaching practice owners. I hope that y’all will find this helpful.
Let’s jump into my conversation with Dr. Kylee Miller.
Hey Kylee, welcome to the podcast.
Dr. Miller: Hi, thanks for having me.
Dr. Sharp: Yes. Thank you so much for coming on and being willing to experiment a little bit with a new podcast format here where we’re going to just dive in and do a live coaching call around some of your questions. So I appreciate you being willing to do it.
Dr. Miller: Wonderful. Thanks for having me.
Dr. Sharp: Yes. Let’s just start. I would love for you to talk about your professional world; what your practice looks like and where you hope to take your practice.
Dr. Miller: Absolutely. I live in two different worlds professionally right now. My main employment is through a university hospital system where I do three-quarters time. So 30 hours a week of testing. I am a testing psychologist with a very narrow scope of focus and that actually applies to my private practice as well.
In my private practice, I have an even more niche focus. I serve people with neurodevelopmental disabilities. I do complex diagnostics on that. And then in my private practice, I supposedly travel. I don’t have a brick-and-mortar. I don’t have to bill insurance. I do evaluations for individuals on death row that have suspected or been diagnosed with neurodevelopmental delays.
I am looking to grow my private practice into continuing to serve people with neurodevelopmental disabilities, but brick and mortar in the town that I’m living in, and parlay my university hospital work life into my private practice.
Dr. Sharp: Sure. We were talking about this before we started to record, but that little niche area of evaluations with folks on death row is quite fascinating. I just want to acknowledge that and say to the audience, I’m sorry, we’re not going to dive into that. We’ve got a different topic here today. Maybe in the future.
Dr. Miller: Absolutely.
Dr. Sharp: Can you say a little bit about what you hope your practice would look like say in six months? If all was going well, what your schedule would look like and what kind of kids you’d be seeing.
Dr. Miller: Right. If all went really well, and it’s somewhat dictated by insurance I think in the state that I’m in, but I would be seeing exclusively kiddos with neurodevelopmental disabilities. I’m actually in the department of pediatrics at the hospital which is new to me. I just moved to this state two years ago. Previously, I was in the department of psychiatry and I was able to see all age ranges. I would love to go back to that. There’s absolutely a need for that in this state. And I would be seeing exclusively those patients.
In five years’ time, I’d love to have students with me. I would love to have other professions. I would love to have an interdisciplinary but definitely, multi-disciplinary clinic. I always work with speech-language pathologists, OTs. So I’m really trying to set up my license, this is another topic, but I’m trying to set up my private practice license to be able to be a supervisory health service provider for other disciplines as well.
And so as I look into these EHRs, I’m really trying to see, what coverage do I need to be able to bill for those services as well? That’s down the road, but financial planning.
Dr. Sharp: Yeah, certainly. Well, I think it’s nice to have a vision as early as you can. So, if you know in your future your ideal is to have a group practice and you’re supervising folks in some allied health services, that can drive some decisions here early on.
Dr. Miller: I think so. Yeah.
Dr. Sharp: Nice. So, could you just say… Let’s see, what would we like to tackle during this call? What is top of mind for you here as you’re launching this other part of your practice that we can get into?
Dr. Miller: I have so many questions, but I think the big umbrella is how do I come out in the black? Is that even feasible in the first year? How much do I have to take in to be able to make money to be able to support myself? Do I have to keep my university hospital job to see the patients that I want or to make money or both? And how does that translate into my fixed expenses, my annual budget, my startup costs, like what does all of that, it was a lot, but what does all that translate to? So I guess for us through the trays, how much money do I need to make to be okay?
Dr. Sharp: Sure. I love it. I think this is a question that a lot of folks who are starting out are being anxious about. That’s what we worry about, right? If I leap into private practice, can I make the money that I need to without drowning?
Dr. Miller: Right. I think I love this.
Dr. Sharp: Yeah. You phrased it like, what do I need to make to just come out in the black? And we’ll see. I think that’s a relatively easy number to figure out, but I always like to think too, what if you weren’t just in the black but you were swimming in black? Ideally, what would you like to have, and is that possible through your private practice? So not just breaking even, but maybe even enjoying it, thriving and being financially totally secure, all those things.
Dr. Miller: Living in the university hospital system, that is a totally foreign concept. Literally, my goal is, how do I continue to serve people, but maybe I need to think, and maybe I need to have a different mindset. Maybe there is a thrive here financially because that would be a game-changer for me.
Dr. Sharp: Cool. Well, we’ll see. Let’s work through some numbers and see what we come up with. I really liked this question. I’ve said on the podcast in the past that a lot of anxiety can be solved with math. And this is one of those cases where hopefully math will come to our aid and help us out a little bit.
Let’s start. Whenever I do something like this with coaching folks, I always like to start with what the expenses are just to give us an idea of what you’re actually going to have to put out each month. And some of that might be a discussion too around what do I really need when I launch a private practice? So, have you done some of that work to have some ballpark of your monthly overhead in private practice so far?
Dr. Miller: Yes, I have.
Dr. Sharp: Cool. So let’s talk through that. Let’s talk through the components that you’ve identified, the things you’re going to be paying for basically. Can you tell me what you’ve gotten so far?
Dr. Miller: Right. I’ve parsed it out so far into two main categories. The first one is startup costs, so one-time fees. And then I have recurring costs that are set- fixed expenses.
Dr. Sharp: Great. Let’s start with those.
Dr. Miller: So, which one would you like to start with?
Dr. Sharp: Let’s start with the start-up.
Dr. Miller: Okay. So the startup costs, I’ve got the attorney fees. I’ve spoken to an attorney twice now. She charges about $550 for a one-time licensing, like an LLC. I currently have a sole proprietorship. And so I’m discussing with her reasons that I would need an LLC. So there’s the startup cost.
The test kits, which having a very… This is part of my question. Do I go for more general assessments at first and not serve the people that I generally serve because mainly I do hearing-impaired, visual impairment, physical disabilities, which requires a very different test battery that is very expensive? So if I were to do that, that would be closer to the $20,000 mark, whereas if I did the typical, have a general cognitive, a general academic, and then a social communication assessment for autism because I can’t divorce myself from that. I will be doing those. That’s more like $6000 to $10,000.
Dr. Sharp: Great.
Dr. Miller: So I’m trying to go through that.
Dr. Sharp: Did you look at the possibility of how much of this might be covered with something like Q-interactive, if you’re open to that option or?
Dr. Miller: I am open to it. I’ve had a terrible time with it with the current clientele that I serve. It is not working. I have almost totally abandoned it. So if I serve a different clientele, I would absolutely be open to it. I’ve used it before. I’ve done it with higher functioning individuals, but as it stands now, no, but I would be open to that.
I’ve also looked into, can I borrow these test kits from anyone for a little while just to cut my initial costs as I start to build up capital to sink it back into the practice? I can’t borrow it from my current position because people are always using the stuff at the hospital. And so I can’t borrow, unfortunately, there.
Dr. Sharp: Okay. So we’ll call it $20,000. I like to be conservative and just shoot for the high side and see where we end up. So let’s keep it at $20,000 and then see where we go.
Dr. Miller: Got you. Okay. And then furniture. I don’t have a number for that yet, but 2 chairs and a table.
Dr. Sharp: Let’s call it $1000. I always ballpark $1000 for an office. You might come in a little bit under or a little bit over, but I think that’s a decent ballpark.
Dr. Miller: Okay. And then a computer. And I just called that $1000 because I was just trying to do even numbers.
Dr. Sharp: Sure. I like even numbers. Would you prefer Mac or windows?
Dr. Miller: Windows.
Dr. Sharp: You’re okay. You might be able to get that under $1000, but that’s a good round number. We’ll keep that.
Dr. Miller: Yeah. And then marketing. I feel like marketing costs, in the beginning, it’s actually a double-dip line item for me because I feel like there’s ongoing marketing stuff. Initially, it’s going to be I think, more time-intensive going out, selling myself to pediatrician’s offices or family practice places, which will require a different level of marketing, and being a little bit savvier on my part because I also have my university hospital position and I can’t detract from that. So I cannot talk about that at all in my marketing. I don’t have a non-compete but I can’t take. And that makes sense. And I don’t want to.
Dr. Sharp: Of course. I think that’s fair. Unless you were, I mean, if you were considering something like Google ads, there’s also often a setup fee that could be between $500 and $1000 just to get your ads up and running. And then there’s an ongoing monthly fee, but yeah, if you are open to the idea of just building relationships and doing the networking thing, then that’s relatively inexpensive.
Dr. Miller: Right. I’m trying to cut costs and keep a budget. So, that was it for my startup costs.
Dr. Sharp: Okay, great. So what do you have for ongoing?
Dr. Miller: I have malpractice insurance which is $2200. So these are annual. Do you want me to break it down annually or monthly?
Dr. Sharp: Let’s go monthly if you’ve got that
Dr. Miller: But I am interested in an EMR that does it all. I’m like, let’s just take the guesswork out of it because I’m already like, oh my goodness, there are so many moving parts here. I’d like to reduce those moving parts in the hope that that drives me towards success.
Dr. Sharp: Of course. I think that makes a lot of sense. So simplifying and consolidating is ideal. I’ll be honest.
I’m not an expert. I haven’t done a lot of work with TheraNest, and this is gosh, at the time of our recording, just ahead of a little series I’m going to do on EHR reviews. So, I don’t have that knowledge yet, but I am going to look at TheraNest.
I will say that something like TherapyNotes or a SimplePractice, I know you can get away around $50 a month and they include calendar notes, insurance billing, keeping track of patient balances, and almost everything you would need to do within your practice. So just to throw that out there as an option. You may be able to get away. And it’s all one unified system. I’m a big fan of keeping everything under the same roof if you can.
Dr. Miller: That is of the most interest to me here. As I launch this truly, the fewer moving parts I have, the better off things are going to go.
Dr. Sharp: Okay. So, just for the sake of our discussion, let’s split the difference and maybe say $75 for an EHR per month. And if we’re a little off on that, it won’t be a huge issue.
Dr. Miller: Okay. And then office ally then goes out the window with that. So that’s not separate. Website, $15 a month. Does that seem high?
Dr. Sharp: No, that seems reasonable.
Dr. Miller: Okay. and then a phone line is $30 a month. That’s with an answering service. Mailbox, it’s interesting that I have this as a line item because I also have an office space, but the reasoning behind that is as you start to do these applications, you have to do all this credentialing, and you have to have a physical address for credentialing, but I’m not prepared to spend $550 a month renting a space yet before I’m credentialed and can actually see people. So you can rent a mailbox here locally very close to where I’m going to have an office and it’s $12 a month. And it is a physical address. It’s not a P.O Box. So that’s where that came from.
All of these are weird little things that I never would have thought about, and I’m not sure if that’s even the right way of going about doing all of this paperwork and starting it up, but to me, it made sense because I don’t want to do the $550. And so, my next one’s office space which is $550 a month. And that is for a single office. It’s to myself in a shared space, but just a room in a shared space.
Dr. Sharp: Is that for full-time or would that be for one day a week?
Dr. Miller: That is full-time. Now it’s not that much less. I can find one for like $425. And it might be the time of year that I’m looking right now and COVID, and all of that stuff that’s dictating these prices. There’s not a lot of real estates here. And so, finding something that’s like a shared office space which is what I’d really like, because again, I’m going to be working at the university hospital maybe forever, maybe not depending on how it goes, but I’d love to have a flex space that I could actually share with someone who’s doing a similar practice, either therapy or maybe assessments, and then we can rotate. I could do two days a week and then call it a day.
Dr. Sharp: Yeah, that’d be fantastic.
Dr. Miller: But I haven’t found anything like that. So right now my line item financially is $550 and then I can use it whenever. That wouldn’t be my choice though.
Dr. Sharp: Okay. I think that’s fair. We can keep it as again, that conservative estimate, but sure, if you could find a situation where you could just rent for a day a week or share with someone and even split it halftime, that would drop that significantly. Well, hopefully, it would be doable. I know geographically, it can be different, but keep that in mind.
Dr. Miller: Hopefully doable. It’s tough here though. And then I have things like a subscription to a HIPAA compliant telehealth something. Is that part of the EHR or is that a separate thing? I haven’t quite looked into that. A document camera. Do I need that? Is that like a monthly thing or is that a fixed overhead? I have a bunch of other little things that add up to a lot but aren’t fully formed thoughts.
Dr. Sharp: Yeah. That’s totally fair. Okay. I think you’ve covered it pretty well. This is a good ballpark of what you might need to launch. And then you know your ongoing expenses. The HIPAA compliant telehealth, a lot of the EHR platforms we’ll have that wrapped up in them. So that should be included in your monthly cost there. But for the sake of, again, just being conservative, I’d rather be surprised with money than be surprised to have to pay money.
Dr. Miller: Yes.
Dr. Sharp: Okay. So let’s do a little bit of math here. So for those ongoing expenses, we’re looking at, let’s see, that’s about $250, $300, so you’re up around, let’s just say $900 for monthly expenses, maybe $1000. We’ll call it $1000 just to have a nice round number. And then with the startup costs again on the high end, I think you’d be looking at around $23000 to start off if you bought…
Dr. Miller: That’s exactly what I had. Yeah.
Dr. Sharp: Cool. Okay. So now let’s dig in and really just figure out how many hours would you have to bill to meet these numbers, right?
Dr. Miller: Right.
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Dr. Sharp: You said before we started recording that you could foresee a big part of your population being Medicaid insured which reimburses about $50 an hour?
Dr. Miller: Yes.
Dr. Sharp: Okay. So, let’s just take ongoing monthly expenses. $1000 divided by $50 is super easy. And so that comes out to 20 hours to cover ongoing monthly expenses.
So 20 hours. Let’s just say, if you’re doing one day a week ballpark, we could call it 10 hours again, to keep things even. That’d be a long day, but it also allows a little bit of flex where you’re testing maybe on that day, but then you’re writing during some other times or something.
Dr. Miller: Yeah, that’s feasible.
Dr. Sharp: Okay, 10 hours a day, let’s just call it four times a month. Theoretically, you have the capability to bill let’s just ballpark $2000 a month. Are you with me on that?
Dr. Miller: Yeah, I’m with you. I’m hanging in.
Dr. Sharp: Okay. Awesome. And this is super simplified, but again, I think we got a pretty good approximation. And maybe months with five weeks, that might be more than that, but four weeks you’ll at least have four, 10 hour days that you can bill.
So, right off the bat, having the capability to bill let’s just say $2000 a month, that easily covers your monthly overhead, which is on the high side. I just want to remind you again. This is like a high estimate. So if you could fill those four days, I think you could easily be in the black, monthly.
Now, if we go back to those startup costs, then if we sit at $23,000, again, this is super simple, but if you take $1000 a month, put it to your overhead, and then take the $1000 each month and put it toward your startup costs, that would take you about two years to pay off, give or take on the high side.
Dr. Miller: Right. I think that something more reasonable would be for me to alter the types of patients that I see to make sure that I’m more financially comfortable when first starting up a business. That’s one of the sacrifices you might have to make.
Dr. Sharp: Sure. Yeah, let’s run through that scenario. The one that we just talked about is sort of like the, I don’t want to say the worst case, because you’d be seeing the patients you really want to see, but on the financial side, that’s probably the least you would make and private practice. So if we did some kind of hybrid, do you have any idea what the private pay rate in your area is?
Dr. Miller: I have no clue. I’m useless. Sorry. I know that.
Dr. Sharp: No, no, it’s all good. So this is a good time. I can just throw in a little suggestion. If you’re trying to devise your private pay rate, I always say, survey people on Psychology Today or websites, try to get a group of like 20 practitioners in your area. And if you can find the average rate for therapy, just add 10% and that can give you a good rate for testing at least to start out.
Dr. Miller: So I was talking, and I think you and I were discussing this before you started recording that I had been interviewing some local people here that were in private practice, who were actually testing psychologists. And they said that they got about $50 an hour for the private insurance because the other number that we were discussing before was how little Medicaid pays. And so, I think that those numbers might be a little high for this area which is crazy because this is a high cost of living State. It’s the second-highest cost of living
Dr. Sharp: Okay. So you’re saying that Medicaid would reimburse $50 an hour, that seems high?
Dr. Miller: That seems high.
Dr. Sharp: So maybe they would reimburse closer to $40 an hour?
Dr. Miller: Probably $35 to $40 an hour, and then private would be $50. But I’m hoping that there’s… I’ve heard that there’s a great deal of variability between what people get reimbursed because it’s up to each individual practitioner to negotiate their rates. And having spoken to people, even at the hospital system, there’s a great deal of variability.
Dr. Sharp: I see. Okay.
Dr. Miller: I’m going to have to educate myself in that.
Dr. Sharp: Okay. Fair enough.
Dr. Miller: All that to say, I don’t know if I’d be comfortable calculating private pay rates higher than $50 an hour because it’s unlikely.
Dr. Sharp: Oh my goodness. That seems super low.
Dr. Miller: Right. Which is part of the reason why I’m terrified because when I crunched these numbers, I’m like, huh, I’m either just giving my services away.
Dr. Sharp: Right. Thinking about the private pay rate in your area, I know that you said that not many folks are doing private pay and the commercial insurance reimbursement is a little bit of a question mark. I’ll tell you what, let’s do a little bit of a hybrid here and say, if you’re able to get some private pay cases since you are pretty specialized and maybe you take some insurance, maybe take some Medicaid at least to get off the ground, I wonder if we could hit an average of $100 an hour for your reimbursement rate between all those sources.
Dr. Miller: Okay. That sounds reasonable.
Dr. Sharp: Okay. So that puts us in a little bit of a different place. If you were to get reimbursed $100 an hour on average compared to that $40 or $50, that changes things. So now you’re bringing in about $4000 a month. You put $1000 toward overhead, and then you have roughly $3000 to put toward other things. So on the high end, that would take you about eight months to pay off the startup costs. And then you would be in the clear for the rest of your life.
Dr. Miller: It sounds a lot better.
Dr. Sharp: It sounds a lot better, right?
Dr. Miller: That sounds a lot better.
Dr. Sharp: That sounds a lot better. Yes. So the short story I think is, the likelihood is that you’ll probably end up somewhere in the middle, maybe closer to, and we’ll see. There’s some market research to do. It’s hard to know what insurance panels reimburse until you start getting those contracts coming in, but the likelihood is that you might end up more around like $75, let’s say. So we’ll split the difference.
So, at least from my perspective, covering that $1000 a month overhead is pretty easy. That seems very doable based on the time that you have to work. And this also doesn’t take into account any of the money that would be coming from your other little branch or private practice where you’re doing the death row evaluations.
Dr. Miller: Right. And those pay well.
Dr. Sharp: Good. So, again, the most conservative estimate, you’re fine on the monthly overhead. And then it might take you two years to pay off the startup costs. But then, more of a best-case scenario, you’re more looking at eight months to pay off the startup costs and then you’re free and clear. And then the likelihood is that it’ll be somewhere in the middle.
Dr. Miller: Okay.
Dr. Sharp: So, how does that feel?
Dr. Miller: It feels better. It’s nice to walk through those. Thank you. Walkthrough those calculations. I still have in my mind the taxes. That’s something that automatically comes out, right? A solo practitioner, it would be like 20% or 25%, I think, for taxes. So automatically, that’s coming out. So my take-home is not very much. And then if you’re talking about retirement and all that stuff, in my mind, I’m like, “I cannot see 100% of the patients that I went to many, many years of schooling to specialize in to see.”
That’s so boring but also nice to know that I can branch out. I can still see some of those people. I don’t have to give that up, but the trade-off is having more control over my schedule, having more control over my finances because then it’s up to me to alter those numbers to slide one way that scale that you just described. And then maybe that opens me up to do other things like doing training in a different way that I don’t currently do now. Taking on different students or publishing different papers. There’s a season for things and maybe it’s a different season for me right now. These numbers really opened my eyes to different possibilities.
Dr. Sharp: That’s good to hear. At least for me, it’s always been helpful just to put things down on paper and know what I’m working with and then you know what you need to do. And it’s not just this scary, like a black ball of a mystery that we don’t know about, you know? And I think it’s important…
I’m glad you brought up taxes. I didn’t say a whole lot about taxes because largely we were talking about how to cover your overhead and then get out of debt. So you wouldn’t really be paying taxes on any of that until you start making a profit, which wouldn’t happen until you’ve paid off your debt in that first year. So taxes, certainly about 25% is a good ballpark to pull out once you get in the black.
The other thing I wanted to say though, too, you had this question at the beginning of, will I ever be able to leave this full-time job or a three-quarter-time job? And the thing to keep in mind, which you’ve maybe thought about is that these fixed monthly costs, that’s as high as they will go whether you’re full-time or part-time. So when you expand to have your private practice fill three days a week or four days a week, the scaling accelerates quickly in terms of how much you’re bringing in and how little that overhead actually accounts for.
Dr. Miller: Right. There’s definitely a minimum amount of hours that you can work, right?
Dr. Sharp: Yes.
Dr. Miller: Yeah, so part of it was like, what’s the minimum amount that I have to work. And then at what point can I start scaling back if I want to change the scope of my work in terms of clients served? This is very helpful. Thank you.
Dr. Sharp: Oh, good. I hope so. And thanks for being willing to walk through this kind of in the moment and experiment with this format. So I appreciate it.
Dr. Miller: I think it’s very useful.
Dr. Sharp: Cool. Are there any other little questions or things to wrap up before I let you go?
Dr. Miller: I don’t think so. Now, that seems much more doable.
Dr. Sharp: That’s great. That’s what I’m shooting for. Doable is good.
Dr. Miller: Yes.
Dr. Sharp: Awesome. Well, it was great to chat with you and work through this a little bit. I’m glad it was helpful. Best of luck as you build your practice.
Dr. Miller: Thank you so much.
Dr. Sharp: All right y’all, thanks so much for tuning in to this new experiment in on-air coaching. Hope that you enjoyed it. If you did, give me some feedback, if you didn’t give me some feedback, email@example.com. I plan to do about one of these coaching calls every quarter. I have a long list of folks who’ve applied to do these calls on a variety of topics. So I’m excited about that.
If you have not subscribed to the podcast, I would love for you to do that. If you have not rated the podcast, I’d love for you to do that. We are at 89 ratings on the Apple Podcast app. Can I get 11 people to jump in and tap those stars in the podcast out to get us to 100? I’m just OCD enough that I want nice even numbers. So can we possibly get to 100? That’s my challenge. That’d be super grateful.
All right. Y’all stay tuned to the podcast. I’ll be back with another clinical episode on Monday. I hope you all are well. Have a great weekend.
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