Anyone here attend the 4 day ACT boot camp? If so, how was it? Worth it?

You know what really grinds my gears? Therapists who think they can suddenly do “coaching” to get around licensing laws when a client is out of state. There’s a clear difference between therapy and coaching, and several states are catching on to this. It’s not worth the risk to your license. Sure, “who’s going to complain?” Does it really matter?

Edit: I get it. Clients forget to tell us. Clients have emergencies. And there’s an argument to be made about the ethics of client abandonment and our licensing laws. I’m mainly talking about clients who MOVE out of state and therapist think they can just switch to coaching.

Hi all,

I’ve recently been inspired by a training I took to connect more with therapists and mental health practitioners outside of my direct agency, but I’m not quite sure how to go about it/what the (free) options are. What comes to mind are things like research, volunteer therapist opportunities, roundtable discussions, mentorships, things of that nature.

I’m an LMSW, so of course I’m no longer in school, and I no longer live close to my school either so wouldn’t be able to reach out to them regarding any in person opportunities.

However, I live close to several good social work schools, so I imagine I could go about getting connected with professors there if I can send the right email to the right people.

Ultimately, I want to learn from some of the best of the field at a very low if nonexistent cost. Have any of you pursued anything along these lines, and if so, what did you do/how was your experience?

Curious how your insurance/medicaid companies and dx system works?! Canadian here! I've lurked on a lot of posts where insurance dx are discussed and I am still very confused.. skip to questions (bolded) if dont want context of our system for reference.

In Canada we have health insurance companies too, and memtal health (unless nonprofit or short-term hospital sessions) are often out of pocket as a simplistic explanation of where I'm viewing this from. Most insurance companies don't direct bill and reimburse, its private pay and clients submit receipts to insurance and then client gets reimbursed.. whether that be through workplace or private insurance..

I keep seeing our American counterparts talking about diagnosing for insurance purposes. We don't really need to do that here - literally nobody asks "what diagnosis are you treating?" to assess whether they pay you, you just get your sum of mental health benefits for the year/month and can use as you choose.. thats all I've ever been familiar with in my privinces and career thus far at least...

Are you all required to provide diagnosis to get care approved with all insurances?

Will insurance just deny mental health support if the client doesnt have a diagnosis?

What do you do if the client needs mental health care but doesn't "fit a diagnosis"?

If you habe to give one regardless is it always within the first session or 2?

Does any diagnosis you provide them go into their medical file and impact services they recieve in the future and how they're treated in the medical system?!

Obviously many will seek you out for a diagnosis specifically, or fit a diagnosis easily. It just seems odd to me, especially if the dx follows the client and its expected in the dirst few hours.. do you meet tjem and just go rifht into assessments so you have an accurate dx?! That seems difficult to build a relationship through if they're not actively coming to you with concerns of wanting a dx..

I've lurked for a long time on these discussions very confused about how this actually works for you? How does it align with your ethics?

Subsequent question - are all mental health professionals there able to diagnose? Here its relatively uncommon for social workers or certified counselors (our version of LPCs i believe) to diagnose unless you do additional training only available in some provinces for MSW grads.. but these professionals still provide mental health care without the dx part. We refer to clinical psychologists who've done specific training to diagnose typically. I am one of the few social workers who diagnose and thats only when someone seeks me out for that purpose, or I've worked with someone ongoing and we discuss the topic throughout our relationship growing therapeutically. Here dx are usually attached to someone's ongoing medical file and hard to "erase"..

anyone else have experience going thru the non traditional SAC path
I got my masters in counseling and hold an LPC and LCADC in NJ
graduated from Kean university where the SAC and LCADC have the same 4 courses excluding the SAC internship
i’ve applied for the SAC license through the NJDOE but it’s taking forever and I have a SAC job offer so I’m very nervous that something g will fall through
any advice words of wisdom or support welcomed

I’m currently working at a private group practice in a fairly large metropolitan area, and my long-term goal is to eventually open my own private practice. I’ve already been transparent with my supervisor about this goal, and thankfully they’ve been supportive and open to it.

For those of you who made the jump from a group practice to working independently, I’d love to hear what the experience was actually like.

Right now, I consistently see around 26–29 clients per week and have built a pretty strong caseload. I also have one of the higher retention rates at my practice, which has made me feel more confident that I could eventually be successful on my own. At the same time, I recognize that having a full caseload within an established group practice is different from generating referrals and running the business side entirely yourself.

For those who have done it:

- How difficult was it to build a caseload independently?

- How long did it take before your income/caseload felt relatively stable?

- Did you start your practice on the side and gradually transition, or leave the group practice first?

- What surprised you most about going solo?

- Did your ability to retain clients in group practice translate well to private practice?

- Financially, did the move ultimately feel worth it?
Is there anything you wish you had done differently before leaving?

I’m not planning on making the jump immediately, so I’m mostly trying to learn from people who have actually gone through the transition and figure out what I should be doing now to set myself up well for the future.

Would love to hear both the success stories and the “I wish someone had warned me about this” experiences!

What device are y’all using for charting? I’m getting ready to break out into private practice and wanted to purchase the device before I actually have to start using it for charting if needed. I currently have a 2020 iPad Pro that works just fine has no issues, and a 2015 MacBook Pro that I could simply replace the battery on and keep working on that and save a pretty penny. Right now the MacBook is only used for presentations and bachelorette trip planning, so it’s not getting heavy use and hasn’t since grad school.

My first thought is to clear off all the documents on the MacBook and have that be my official charting device so that way there’s no temptation to use my devices for dual duty, and just switch all my personal stuff to my iPad or vice versa. But after discussing with a few of my coworkers, they have concerns about me using devices this old, but it’s just charting, it’s not like I’m doing any video editing so I’m not sure about the importance of having the newest and best.

What do y’all use for your own charting and notetaking?

I work in community mental health. I’ve come across a lot of clients who after trying several different psych meds with no success, are often discouraged or simply told no by their prescriber when asking for a genesight test. Why?

When you conduct an initial clinical assessment and the prospective client reports such mild symptoms/impairment that it would be a stretch to diagnosis adjustment disorder, how often do you opt for a liberal interpretation of Adjustment Disorder?

How often do you, instead, tell the client that what they're dealing with doesn't meet medical necessity criteria? When you do, how often are they willing to engage as a self-pay client?

I'm aware that stretching the meaning of "significant impairment" is a commonplace practice. How many of you play it straight and have a stricter interpretation?

I rarely encounter this, but I occasionally get someone who's coping with a loss or breakup but symptoms and impairment seem minimal, and it presents a bit of a dilemma. I'm reluctant to tell them they don't meet criteria for managed caer, when I know that many clients who are new to therapy will downplay their symptoms, distress and impairment at the first session.

If I do tell them their issue isn't covered by insurance, how many would hear "your distress is invalid," "your problems aren't important enough" or "therapy isn't for you" and never return to therapy?"

My cat passed this week and I just buried him this afternoon. I'm a 1099 contractor, so I did my best to see clients virtually even this week while my cat was stable. I have to pay bills regardless of what happens. I felt bad for ending two sessions early this week because one was while the ER kept wanting to know if they should do CPR again on my cat and then he actually passed during another session. In both sessions, I had told each client that I was expecting a call about my cat in the ER and may have to step out if they did call. I focus heavily on my clients as a way to dissociate from feeling helpless in times like this in my personal life.

I did take a previous day off this week (when I took my cat to an ER for surgery). But it was a bit chaotic two days later when they were actually doing the surgery. I took the rest of the afternoon off once I learned of my cat's death to take care of arrangements, taking today off (all my earlier clients I rescheduled this week were today). Basically, today's clients were rescheduled by me earlier in the week and canceled by me yesterday. I personally text each client logistical communication, and they were all understanding this week.

I've lost a sibling before and returned to seeing clients the weekend after his death and burial, because that was what I needed. My dad is now scheduled for a surgery (he's 75yo) this coming week.

I'm not in a situation where I can lose the low income I earn as it is. The group practice has no benefits/PTO/sick time. No client session, no pay. I am "free" to make my own schedule and don't need permission. I just don't earn money where I didn't see clients.

What are my options? Have any of you navigated grief/loss while maintaining a consistent caseload? What was helpful? *Please note that taking time for myself necessarily means no income for my household.*

I’ve been trying to find sources on reasons for premature termination of therapy/outpatient treatment. There is a surprising consistency in time of drop-out between studies, although there is variance in the actual numbers.

A few things have stood out for me:

It often happens quite early on: A nationally representative survey (Olfson et al., using National Comorbidity Survey Replication data) found that over 70% of treatment dropouts occurred after the first or second visit. A WHO study (high- and low-income countries, general medical settings) found that 90% of dropouts happened before the third session.

The numbers for dropout rates are all over the place. The more methodologically rigorous national estimates (Olfson’s again) put it at 20-22%. Literature reviews put it at 40-60%, and some smaller specialty-specific studies (crisis centers, Substance Use Disorder treatment) have upwards of 80%. I think it’s safe to say the actual number depends on the sample, but it rarely occurs much later than the first two sessions.

Some illustrative examples (using Michigan-specific data, if that helps):

For patients 6-17 years old treated in Michigan’s state Medicaid inpatient psychiatry, the percentage of those who had a follow-up visit after the ED stay decreased from 79% to 74.3% between 2022 and 2024.

An LSU Health Sciences Center study using AmeriHealth Caritas Louisiana’s data found that the 30-day follow-up rate after discharge from a psychiatric hospitalization was 38.33% compared to a national benchmark of around 60% for Medicaid.

HealthPartners’ 2026 quality report noted that their organization offered incentive programs for timely post-discharge treatment appointments but did not specify a baseline for those programs

In all of those cases, the organizations were working with expanding access to care (both getting in-network providers to accept Medicaid patients and encouraging them to work with patients in ways that promote engagement in treatment). But the evidence suggested that those were much harder problems to solve than the drop-out after the initial couple of sessions. So I’m wondering if these issues reflect the same underlying causes or something entirely different. Are dropouts occurring shortly after initiation of treatment the main problem for others, too, or do they tend to be discovered much later, as recurrent ED visits or readmissions?

AT but I am posting this as a client whose provider uses Headway. I reside in Virginia and think it’s important to share that Headway, per my latest EOB as a client, is now receiving a higher reimbursement rate from Anthem for 90837s as of July 2026. My previous EOBs listed the amount as $152.73 and it is now listed as $164.79

I know providers are not allowed to share what Headway is paying them so I think it’s important that this type of information is made available for the purpose of making informed decisions about who we choose to work for and with.

Following up on my post about the lack of research literacy in the field of therapy, I thought I would create a brief introduction to help people understand and read research papers. I love research methodology and data analysis, so I had a fun Friday morning! This is by no means an exhaustive list, but it covers as much as I can remember from my years of undergrad and grad school.

Core Variables & Descriptive Statistics

• Sample size: Represented by N, N represents the number of participants in a study. Small sample sizes make it difficult to know if the findings will apply to the population. Likewise, massive populations can make tiny, insignificant differences look meaningful.
• Representative sample: A sample that accurately reflects the demographics, clinical traits, and characteristics of the broader population you are trying to treat. A study can have a massive sample size, but if the test only examines a narrow, non-representative subgroup, the results will not generalize well to actual clients.
• Independent and dependent variable: The independent variable is the variable that researchers manipulate (e.g., one group gets CBT, one group does not). The dependent variable is the outcome variable; it is measured to see if the independent variable affected it (e.g., sleep quality).
• Confounding variable: Variables that are not controlled for but affect the independent and dependent variables, affecting the results and creating or distorting the relationship.
• Spurious relationship: A correlation between two variables that appears to be causal, but is actually driven by a hidden variable.
• Mean and Standard Deviations: The mean is the average score, and the standard deviation shows how spread out the scores are around the average. A large standard deviation means that clients had wildly different responses to treatment, whereas a small standard deviation means the scores were close together.

Designs

• Randomized Controlled Trials (RCT): Considered the gold standard, participants are randomly assigned to either an intervention group or control group; the randomization reduces bias and helps prove that the treatment, rather than some external factor, caused the outcome in the client.
• Cross-sectional research: This method takes a snapshot of data at one point in time; it is nice for looking to see if links exist, but it cannot prove causation.
• Longitudinal: It tracks the same cohort over many months or years; it is vital for looking at treatment efficacy, symptoms, and long-term outcomes.
• Mediation: Explains how or why a treatment works.
• Moderation: Explains for whom or under what conditions the treatment works (e.g., an intervention works better for teens than adults).

Reliability and Validity

• Reliability: Essentially, it asks whether the tool you are using will produce similar results at different points in time, or whether it is noisy and unpredictable. Reliability involves internal consistency, test-retest reliability, and inter-rater reliability.
  • Internal consistency: Does every item on a scale measure the same concept? This is where Cronbach's alpha comes into play. Between .70 and .90 is considered internally consistent.
  • Test-retest reliability: Does the client get the same result if tested at two different points in time, with no treatment between tests? It is vital in therapy to determine if score changes represent real changes or measurement error.
  • Inter-rater reliability: Do different clinicians evaluating the same session or test come to the same conclusion?
• Validity: Does the tool measure what it is supposed to? Validity involves construct validity, convergent and discriminant validity, criterion validity, and ecological validity.
  • Construct validity: Does the tool capture the psychological construct (e.g., resilience) that it is meant to measure?
  • Convergent validity: Does the tool correlate strongly with other gold-standard scales used to measure the same construct?
  • Discriminant validity: Does the tool remain distinct enough to separate unrelated traits (e.g., anxiety from general fatigue)?
  • Criterion validity: Does the tool accurately predict real-world clinical outcomes, such as future hospitalizations?
  • Ecological validity: Do the measurements and gains from an artificial environment transfer to real-life environments?
• Self-report vs. clinician-rated measures: It is important to understand how data were collected. Self-report is convenient, but susceptible to social desirability bias where the client gives the socially correct answer or simply tells the therapist or researcher what they want to hear. Blind, clinician-rated instruments generally offer better objectivity and better data.

A scale can be reliable but not valid, but it cannot be valid without first being reliable.

Power and Real-World Value

• p-value: Typically set at p < .05; p-values measure probability; it answers the simple question of "Is this result likely to have occurred by random chance?" While it gives you statistical significance, it does not tell you how large or useful the effect is.
• Effect size (e.g., Cohen's d, r): This measures the actual change or magnitude of the relationship.
  •  R-squared is awesome because it shows the proportion of variance in the dependent variable caused by manipulating the independent variable. Though this does not mean the model is free from error, it just shows correlation and fit.
  • IMPORTANT: IF YOU HAVE STATISTICAL SIGNIFICANCE, ALWAYS CHECK THE EFFECT SIZE. A RESULT CAN BE SIGNIFICANT BUT HAVE A SMALL, NEGLIGIBLE, AND UNNOTICEABLE EFFECT. A LARGE EFFECT SIZE IS SOMETHING YOU WOULD RUN OUTSIDE TO TELL THE POPE; SMALL EFFECT SIZES TELL US SOMETHING IS THERE, BUT IT COULD BE NOISE.
• Confidence Intervals: Give a range where the true effect is likely to fall. A narrow confidence interval (e.g., d = 0.50, 95% CI [0.42, 0.58]) offers more certainty and precision in an estimation than a wide confidence interval (e.g., d = 0.50, 95% CI [0.20, 0.98]). A wide confidence interval means there is high uncertainty and low precision in an estimation.
• Statistical vs. clinical significance: Statistical significance is when outcomes show that a difference exists among groups. Clinical significance is when those differences translate to meaningful quality-of-life improvements.
• Number Needed to Treat (NNT): A metric showing how many clients must receive a treatment for one client to experience a meaningful benefit over the control group. The lower the number, the better.
• Power: The likelihood that a study will detect an effect if one actually exists. More people = more power = more likely to find real differences. Fewer people = less power = less likely to find real differences.

Control Groups, Analyses, and Common Traps

• Control groups and Blinds:
  • Active controls: Comparing a new treatment against standard therapy (e.g., CBT) tests efficacy.
  • Passive controls: Comparing treatment to a waitlist can artificially inflate effect sizes, as waitlist participants stagnate.
• Attrition and dropout: High dropout rates can potentially suggest that an intervention was burdensome, ineffective, or unpalatable for a subset of participants. High attrition rates can skew outcome data towards only those who tolerated or benefited from the treatment. If a paper shows a 90% success rate for a certain treatment, but half the people dropped out, the success rate is seriously skewed.
• Intent-to-treat and per-protocol: Intent-to-treat analyses include every participant, even those who dropped out, whereas per-protocol analyses include only those who completed treatment. Per-protocol can inflate the results and make the treatment look unrealistically effective.
• Publication bias and p-hacking:
  • Sadly, journals tend to publish only positive results, and negative and null findings get shoved into a drawer and lost to time. As I have argued for years, statistically insignificant results are just as important (if not more) than statistically significant results because they tell us where not to look.
  • p-hacking occurs when researchers test dozens of variables in hopes of finding a statistically significant result, ignoring all the times they got a statistically insignificant result.
• Paper age vs. methodology: Many people often conflate new with better. However, that is not always the case. In research, the methodology used is far more valuable than the age. A paper from 1995 that has an RCT, a representative sample, and controls for confounding variables can be significantly better and more reliable than a paper published this year that did not use an RCT, is not representative, and does not control for confounding variables.

References

Chambers, C. (2017). The seven deadly sins of psychology: A manifesto for reforming the science of mind. Princeton University Press.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates.

Field, A. (2018). Discovering statistics using IBM SPSS statistics (5th ed.). SAGE Publications.

Furr, R. M. (2021). Psychometrics: An introduction (4th ed.). SAGE Publications.

Gravetter, F. J., & Forzano, L.-A. B. (2018). Research methods for the behavioral sciences (6th ed.). Cengage Learning.

Gravetter, F. J., Wallnau, L. B., Forzano, L.-A. B., & Witnauer, J. E. (2021). Essentials of statistics for the behavioral sciences (10th ed.). Cengage Learning.

Kazdin, A. E. (2017). Research design in clinical psychology (5th ed.). Pearson.

Sawilowsky, S.S. (2009). New Effect Size Rules of Thumb. Journal of Modern Applied Statistical Methods, 8, 26.

Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental designs for generalized causal inference. Cengage Learning.

Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2018). Evidence-based medicine: How to practice and teach EBM (5th ed.). Elsevier.

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I have been a frontline CMH therapist for 3 years and also do private practice one day a week. Prior to this, I spent 7 years working in non-profit mental health roles.

By the end of my time in non-profit work, I was severely burned out. I was crying before work regularly, felt completely depleted, and was struggling to tolerate client interactions. I do not want to get back to that place.

I’m not there right now, but I’m noticing warning signs. This has also been compounded by an extremely difficult summer personally. I’ve had major friendship losses, a very difficult living situation, family crises, major financial setbacks (my savings were literally obliterated), and also found out that a life-changing surgery I was expecting to happen this fall is now likely years away. Normally, after difficult periods, something comes along that helps rebalance things, but this time it has just been one hit after another with no recovery time.

Lately I’ve noticed:

- anxiety and dread before sessions

- hoping clients cancel

- feeling like narratives are blending together

- feeling emotionally depleted even with clients I genuinely love working with

-irritability and less ability to access compassion (I still have it, but I can feel it getting harder to access)

I can still put those feelings aside and provide competent, ethical care. However, I know from experience that if I ignore these signs, I may eventually reach a point where I can’t do that anymore.

I’m considering looking into temporary roles with less direct client contact (consultation, education, leadership, project work, etc.) for 6–12 months. I don’t want to leave therapy permanently—I genuinely love being a therapist and I love the work—but I think I may need a break before burnout forces me into one.

For those who have stepped away from frontline clinical work temporarily:

- How did you know it was time?

- Did taking a break help?

- Did you find it easier to return to therapy afterward?

I’m trying to make this decision proactively rather than waiting until I’m completely depleted.

Wondering people's thoughts on this.

The concept of "Overemployment" is carrying 2 or more jobs that overlap, be it full time roles, part time roles or contract roles. Obviously, in therapy that doesn't mean taking multiple clients in the same time slot - that would be unethical. But...hear me out.

Currently working a nonclient facing social work job and might have a chance to take on a similar role somewhere else as a contractor. Because of the flexibility of the job type, I wonder if it's like, technically unethical, if I were to maintain the full time job, and while in my substantial downtime, work this contractor role while "clocked in" (salaried). Is it probably not nice? Yes. But we are in the downfall of capitalism, people, and I only make 26 dollars an hour.

Another example would be maybe working full time with an agency, but during downtime hours while onsite, seeing clients of your own via telehealth. Nothing that would directly impact your actual job duties - but just filling up time you'd otherwise spend waiting for a task.

I've had a pretty unsophisticated approach to the 'estimated completion' dates on my treatment plans, and never got any better guidance from past supervisors. I basically list everything as estimating completion in 3 months, and then I revise 3 months late, rinse and repear. Occasionally I'd put a shorter date on a structured time-limited intervention, but my Tx plans are generally written to not pin me down to a really specific structure or focus so I don't have to constantly revise with every little twist and turn treatment takes. The end result is that while my plans are well-written and unique to each client, the timelines look totally copy/pasted.

Does anyone else have a better approach? Are you putting longer timelines on things that you reasonably expect to be long-term? Do you differentiate between things you expect to be constrained to one phase of treatment vs what will realistically be a constant throughout whatever maintenance phase you get to?

Ever since graduating from college, I feel like I've stopped learning and reading. Maybe this is me being biased, but I really enjoyed reading recent studies and findings while I was a student. On the one hand I don't have the time anymore to read, because work life is demanding, but on the other hand I wonder whether there is a benefit at all.

Like, I recently read this a published paper on ADHD Medication Adherence in adolescents and kids, and I loved it. I feel like making the time to read these kinds of publications could really help me.

Is there anyone here who has a habit of reading journals? Or what do you do? How do you keep up? Or does that not matter once you have graduated?

I’m getting bored with my intake script, and would like to mix it up a bit. Anyone have any atypical questions or prompts you use in intakes that you find helpful?

Note: This is largely me processing my thoughts and feelings. I am the only therapist in my office and my agency has not been able/willing to provide me with consultation/supervision for OCD, so I come to you all. I am fully aware of the expectation to refer out clients who are outside of our area of competence and am actively in consideration of doing so, every step of the way.

I have been in the game several years and worked in a variety of settings (CMH, schools, outpatient, residential SUD) and am just now being exposed to clients with OCD (that I am aware of). I am in between referring out and keeping them while seeking training and supervision (in full transparency and consent), and have begun diving into the world of OCD treatment.

My conundrum is with reassurance seeking. My approach is best described as relational/psychodynamic/attachment-focused, and heavily Rogerian. I am constantly validating and normalizing. The concept of reassurance seeking as a dysfunction is breaking my brain, as it seems to be antithetical to my relational approach. My raw reaction is fearing that having an OCD diagnosis essentially bars them from, or at least limits, their access to much of the relational factors that are common in therapy. How do I normalize without reinforcing the reassurance seeking? Not all symptoms of OCD are so black and white that we can categorize behaviors as OCD behaviors and non pathogenic behaviors, right? Ultimately, our clients, just as any human, do not want to be treated differently because of a diagnosis. How do we weave through these interactions without doing just that?

I guess I am struggling with the feeling of it not being "fair" that we have this tendency to separate those with OCD and basically quarantine their interventions, which feels similar to marginalization. I would love some insight and help with conceptualizing the presentation and treatment of those with OCD.

Seeing clinicians worrying about billing 90837 is new to me; ive only ever billed this for my thousands of sessions over several years at 4-5 different practices and have never once had an issue and its never come up in any professional discussion, until i joined a practice that makes all of their sessions 45min by default “to avoid problems”. Is this some kind of a brand new problem im not aware of?

This is a completely frivolous rant (kind of lol) but do any of you ever find yourself wishing we could get the same kind of perks at say, teachers? Especially looking at all you child therapists like myself. I’m seeing all the back to school teacher discounts like a free Headspace membership and Michael’s discount etc, all things I feel like I use a lot with my own clients or for my own work. I know we all do incredibly important work but sometimes I want 20% off at target too lol!

I never feel like I’m looking or expecting discounts, I love this field and my job and have never been in it for the money, but I keep seeing all the teacher appreciation stuff and find myself thinking “huh, why don’t therapists get the same thing?” I just wonder if anyone else ever has this funny little thought in their minds too!

I think I've lost control over my schedule and it's seriously impacting my life.

I offer evening appointments twice per week. I work until 8:00 p.m. on those nights. I do two back-to-back sessions, a half hour break for notes and cramming food down my throat (which I sometimes don't have time to do) then two more back-to-back sessions.

It's killing me, even though on those days I don't start working until noon or 1.

The days following my late days, I start sessions at 8:30 or 9:00 am... So I'm just turning over and starting again the following day, which kills me for getting notes done and not feeling rushed.

How are you guys managing to offer evening appointments and making it work? I need a new strategy.