Building a Business as a Neurodivergent Therapy Practice Owner with Dr. Amy Marschall

Dr. Amy Marschall  [00:00:00]:

One of the insurance companies that had been giving me just issue after issue and forcing me to call and spend hours on the phone arguing about why they should pay for the service, in theory, what they're supposed to do for their customer who gives them money. And I finally said, I'm not dealing with you anymore. And I decredentialed. And that freed up several hours a week of my time.

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Michael Fulwiler [00:00:24]:

This is heard business school, where we sit down with private practice owners and industry experts to learn about the business of therapy together. I'm your host, Michael Fulweiler. Therapists hold the key to deeply understanding human connection, a cornerstone of both healing and business success. But how do they translate this profound insight into a thriving practice? My guest on this episode of Heard Business School is someone who has mastered this balance beautifully. Doctor Amy Marshall. If you've come across her insightful writing or social media content, you'll recognize her as a powerhouse in the mental health field, especially within the rural and autistic community. Doctor Amy isn't just a psychologist, she's a writer, trainer, consultant and entrepreneur. Widely recognized for her expertise on telehealth and psychological assessment.

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Michael Fulwiler [00:01:18]:

She's also hilarious and we've become friends after meeting on Twitter. In our conversation, Doctor Amy emphasizes the importance of specializing in a niche and the powerful impact of creating valuable content for that niche. Doctor Amy also shares the nitty gritty of running a private practice, including hiring, administrative support and setting firm boundaries to prevent burnout. Doctor Amy's therapy business journey is a testament to innovation and dedication in mental health practice. Here's my conversation with Doctor Amy Marshall. Enjoy.

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Michael Fulwiler [00:01:53]:

Doctor Amy Marshall, welcome to the show.

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Dr. Amy Marschall  [00:01:55]:

Thank you for having me. It's good to be here.

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Michael Fulwiler [00:01:58]:

Very excited to have you on. We are Twitter friends, which I think I've heard you describe as pocket friends, which I love.

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Dr. Amy Marschall  [00:02:05]:

I did not coin that, but I cannot for the life of me find who said it first. But it's the people who live in your pocket, right?

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Michael Fulwiler [00:02:13]:

Yeah. So nice to bring that relationship to somewhat real life, I suppose. I guess we're still virtual. You also do all of the things as an entrepreneur. You are a therapist, of course. You also do assessments. You are a writer, an author, a trainer, a consultant. So I want to dig into all of these.

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Michael Fulwiler [00:02:37]:

All of those things. You also have ADHD, which I want to talk about. I don't know if there's a relationship between those two things or not.

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Dr. Amy Marschall  [00:02:44]:

Yeah, the dopamine seeking is definitely there. It helps. I'm ADHD and autistic, so I get the hyper focus and the dopamine seeking. So I'm all over the place all the time.

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Michael Fulwiler [00:02:55]:

Fascinating. I definitely want to talk about that from a business perspective before we get into all of that. After graduate school, you worked at a group practice. What was that experience like for you? Kind of as a first step into the field.

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Dr. Amy Marschall  [00:03:11]:

So I think, I don't think I could have done private practice immediately out of my postdoc just because graduate school really doesn't touch the business side at all. So I had no idea what I, you know, we didn't learn about referral sources. We didn't learn about health insurance. We didn't learn about overhead, renting an office. Like, they just kind of throw you out there. So it was, I think, good to have the experience where there were admin staff who, they had me do it myself, but they had people, like, walking me through credentialing with insurance, you know, tips on forming relationships with referral sources and things like that. Those things, honestly, once you're doing them, it was not as complicated as I made it out to be in my head before I started doing it myself, but it was good to have some, somebody to kind of have my back with that as we were doing it. Although now everything, with so much being online, I think the overhead that I was concerned about with the private practice, it's a lot easier to do it for less because I sublet an office one day a week, so I can still do the things in person that need to be done in person, and I don't have to pay for an office the rest of the time.

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Dr. Amy Marschall  [00:04:31]:

I just. I have my home office right here, which is a write off, which is nice. So I not only don't pay for it, but we save money because I have a home office that this room in our house is my office and nothing else.

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Michael Fulwiler [00:04:44]:

So if the IR's is listening, yes.

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Dr. Amy Marschall  [00:04:48]:

If anybody is listening, I follow all the laws very carefully. I want to be very clear about that.

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Michael Fulwiler [00:04:54]:

So what was that transition like for you, going from the group practice to starting your own practice?

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Dr. Amy Marschall  [00:05:00]:

It was nice that I did kind of have the leeway to take as long as I needed to. The biggest thing for me is that I'm a Medicare and Medicaid provider. Medicaid just South Dakota, because other states won't let me take Medicaid even though I'm licensed there. They won't let me take it because I'm not a resident of that state and I don't have an office address in that state. So for potential clients listening, I get asked a lot. Do you take Medicaid in these other states? I want to. I very badly want to call your reps and tell them to let me, but basically it takes forever to get that moved over. So I was able to initiate the process but keep my Medicaid clients at that practice and not move them until I had it turned on at the new practice.

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Dr. Amy Marschall  [00:05:47]:

But it kind of, it fell together really nicely because the office that I was initially subletting, their organization, needed someone to, as a supervisor for Medicare in order for certain licensures to accept Medicare. And I was looking for a space, and they said, hey, we'll trade you an office space for this supervision, which worked out really nicely until the law changed. Now I've actually got to pay for an office, so. But, yeah, it kind of, kind of all fell together and was like, really good timing and just seemed to work.

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Michael Fulwiler [00:06:19]:

Did clients come with you from the group practice to your private practice? And I was okay with the group.

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Dr. Amy Marschall  [00:06:24]:

Practice and, yeah, so I like that we're looking at banning non competes because on principle, I don't like those. But I don't understand how anyone could ethically try to enforce, like, you're not allowed to offer continuity of care. Like, how is that ethical? The group practice that I was at doesn't do non compete, so that was not an issue for me because they understood that that's not ethical, so they never tried that in the first place. That's part of why I, why I was working for them. I asked about that in the job interview. I think every single one of my clients did come with me when I shifted over. And, you know, my referral sources, I just let them know, call me at this number instead of that number. Now here's my new email address.

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Dr. Amy Marschall  [00:07:09]:

So it was pretty smooth in that sense.

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Michael Fulwiler [00:07:11]:

How did you think about the financial side of your practice? Did you set up a bank account or did you already have one set up from working at the group?

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Dr. Amy Marschall  [00:07:21]:

I had all my personal accounts, so I just, when I registered the, it was an a PLLC. Now it's an s corp. But when I registered the PLLC, I just got a business checking account and a business credit card with my same bank and just everything, you know, deposits into the business account, and then I pay myself.

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Michael Fulwiler [00:07:41]:

And were you doing your own bookkeeping in the beginning?

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Dr. Amy Marschall  [00:07:45]:

You know, that heard does my bookkeeping.

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Michael Fulwiler [00:07:47]:

Yeah. At what point did you partner with heard?

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Dr. Amy Marschall  [00:07:51]:

Yeah, that was, I think, right away, like, right when I started making money through the private practice. Just, I adhd. I'm not going to do my own bookkeeping. I'm not going to do my own stuff. So I just want to be able to hand the pile to somebody and say, you figure this part out and.

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Michael Fulwiler [00:08:09]:

You'Re based in South Dakota, which you mentioned. I'd love to dig into some of the unique challenges of building a practice in a more rural setting.

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Dr. Amy Marschall  [00:08:19]:

Honestly, I would. And granted, well, I am licensed in New York as well, so I've got a little bit of both going on. But I found that the rural referral sources are really easy to pick up because there's fewer people, but there are like no providers. South Dakota has the lowest number of licensed psychologists of any state in the country and we're in the bottom three for number of mental health providers per capita. So we not only have fewer providers, but we have fewer providers relative to the total population than most places. So really I don't have to market very much. Just people are like, oh my gosh, somebody you know.

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Michael Fulwiler [00:09:03]:

Right. How do you build relationships with those referral sources?

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Dr. Amy Marschall  [00:09:09]:

When I first moved to South Dakota, I just made a list of gps and pediatricians because I work with a lot of kids and I just reached out and said, hey, I'm a licensed psychologist. Here's the insurances I take. You can tell your clients about me. And honestly, I really only had to do that for a month because then they told each other about me. It's unfortunate really, because there is such a need, but I don't really have to do much for marketing because they find out about me and then they tell their friends and they tell their friends and I get a lot of clients who will say, oh, you're, you know, this person told me for my assessment practice, I'll assess my way through friend groups because they'll say, hey, there's a reason we all click. Here's who did my evaluation. Give her a call. And it doesn't.

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Michael Fulwiler [00:09:59]:

Yeah, people find me because there are fewer therapists. Do you find yourself seeing other types of clients? I imagine in a more rural setting, therapists operate more as generalists just because there's fewer specialists. Is that the case?

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Dr. Amy Marschall  [00:10:17]:

Yeah. So the, you know, there's scope of practice and that's important and you do have to have boundaries around that. And also the, the hard limits of your scope get a little bit more gray when you're in a rural area because the ethics code says, don't see someone you're not trained to see. But if you can't make a referral, you figure it out and you just do it. So that was my pre doctoral and my postdoctoral training in Arkansas through the National Psychology Training consortium. Their whole thing is rural mental health. So there was a lot of. I worked under a psychologist in private practice.

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Dr. Amy Marschall  [00:10:57]:

The next closest clinic to us was 50 miles away. And this was back in 2014 before everybody was doing stuff online. So it was, you know, people would come in with complex presentations. People would come in who had, you know, kind of like a peripheral, not like, you know, we're not seeing our own family members. But, you know, my. My supervisor, my employer had kids, and he was the only psychologist in town. So when his kids classmates needed to be evaluated, he was like, well, either I figure out how to balance this dual relationship or this child doesn't get the help they need, so you just. You figure it out so that people aren't left hanging.

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Michael Fulwiler [00:11:40]:

What is that experience like, personally? Because I imagine in a more rural setting, you're more likely to run into clients or run into your own therapist.

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Dr. Amy Marschall  [00:11:48]:

That's why I like telehealth very much, honestly, because my North Dakota clients aren't going to bump into me at the grocery store. My Montana clients aren't bumping into me out in public or anything. So. So I like telehealth. I also like licensure, reciprocity, because that brings more people. South Dakota is Psi packed now, so any psy packed psychologist can see someone who's in South Dakota. And that's huge because when I'm like, I don't know, like, I can't see you for whatever reason, and I don't know who to send you to because there's nobody else. Now I can be like, hey, here's a huge list of people who have now been approved to practice here.

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Michael Fulwiler [00:12:29]:

How do you reach clients who live in other states? Because I imagine local marketing is easier to drive around town and build your referral network.

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Dr. Amy Marschall  [00:12:40]:

People find you online all the time. I'm on a couple of listings. I don't spend a lot of money on directories, but neurodivergent therapists, nditherapists.com, you pay a one time fee and then you're there, you know, for life. So I just, like, a lot of people find me there. I don't like the, like, you know, they're not. They don't exist anymore. But the Kardash like websites that just, like, make up a profile for you, I don't like that. But I do like when someone who, and I'm not.

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Dr. Amy Marschall  [00:13:12]:

I'm not saying my clients need to do this. But I've had a number of times that someone who had a good experience with me will just like list me somewhere. So like PDA America, pathological demand avoidance. It's not a recognized diagnosis yet, but basically someone that I did an autism eval for who had PDA traits joined this organization and they were like, we need to list providers that we know do a good job. And so then they just like, put me on their website and linked me. And so people were finding me through that. I think it's New York Autism society or something like that listed me and people like, find me through that all the time. So kind of once you get rolling, I mean, the Internet, everybody uses the Internet to find stuff, so if you've got the web presence, people will find you.

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Michael Fulwiler [00:14:00]:

Exactly. It sounds like having a strong niche or specialization really helps with word of mouth. Could you talk about your niche and the types of clients that you work with?

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Dr. Amy Marschall  [00:14:11]:

My specific niche is also really helpful because the autistic community in particular are going to tell their friends about the things that they like. So if you do a good job with your autistic clients, they're going to tell everybody about you. They're going to call you and they're going to, yeah. So it's, it kind of the, you know, the snowball starts and then it follows itself. So that's, I don't know if other niches have that same experience, but my autism assessments in particular, it's a lot of, they tell people about me. My, my blog gets more hits from Reddit than any other social media site, and I don't use Reddit.

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Michael Fulwiler [00:14:54]:

Interesting.

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Dr. Amy Marschall  [00:14:55]:

Just because other people shared me there so many times that I get hits from this website that I don't even use.

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Michael Fulwiler [00:15:01]:

No, I mean, that's a really great point about creating content. You know, writing articles, writing blog posts, putting that on your site that people find and share and people sharing your stuff with other people without you even being involved, I think is a really great signal.

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Dr. Amy Marschall  [00:15:20]:

You share something and even the people, like, for every person who contacts me from that article, it's really good to know that however many people probably read it and benefited from it but didn't end up needing, like, my actual services. So that's actually, that's how I got into writing, was I had no more availability and people kept calling and I was like, how do you support more people when there's only so many clinical hours you can do in a week?

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Michael Fulwiler [00:15:45]:

Yeah, definitely. And I think you do a really great job of that both writing for your own blog, but you also write for other sites as well, right?

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Dr. Amy Marschall  [00:15:54]:

Yep. Very well. Was the well, I started out with the uptake, which is a community journalism local paper out of Minneapolis that they needed a psychologist to do, or I guess wanted a psychologist to do some articles on mental health in 2020 with everything. And then I ended up doing several pieces for them. And then from that, I was able to get in with dot Dash Meredith, which is who oversees very well. So now I've written for them. I've written like, they're the parent company of a bunch of things. So I've written for, like, health.com, comma, parents.com, people magazine, apparently, which I did not realize was happening.

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Dr. Amy Marschall  [00:16:37]:

So I did a, they wanted someone to review several different telehealth options for group therapy. So the brief that I got said group therapy for people. And I was, I was like, what a funny name to give it. Like, group therapy for who? Like, right. All of our.

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Michael Fulwiler [00:16:57]:

Not for dogs, but for people right now.

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Dr. Amy Marschall  [00:16:59]:

Yeah. Like, okay, that's a weird title, but I'll do it. And then I got the alert that it was published. I was like, oh, group therapy for people. That makes sense.

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Michael Fulwiler [00:17:13]:

I want to go back to starting a practice. Sounds like the experience, actually, of starting a private practice was pretty smooth.

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Dr. Amy Marschall  [00:17:21]:

Yeah.

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Michael Fulwiler [00:17:22]:

But looking back, were there any mistakes that you made or anything that you would have done differently? Knowing what you know now, I wish.

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Dr. Amy Marschall  [00:17:31]:

I had done it sooner, honestly. Because just, you know, if you want to work for a group, if that's what works for you in your life, that's awesome. You know, everybody needs to do what they need to do. But the big thing is, like, with the group, you, you know, you work and you generate revenue, and then the group gets a cut of what you bring in. And it's kind of a, you got to ask yourself, what value am I getting from sacrificing this percent of my income? And really, you know, the main thing it became was that they had an admin who answered the phone for me. They helped me out with billing, and they gave me an office space. And, you know, starting in 2020, they really weren't giving me an office space anymore. And by, you know, any group practice owners listening, if you had your employees switch to working from home and you didn't give them a pay bump for using their house as an office and saving you money on office space, like, you should.

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Dr. Amy Marschall  [00:18:29]:

Like, you should be giving them a bump for that because that's a reduction in the value that you're providing your employees. But the mindful admins does part time admins and you just pay by the hour for what you need from them and they're fantastic. And actually, I've been dealing with some medical stuff lately and the admin that I had through them has been fantastic. Her name is Dane and I love her and I, like, I had to last minute cancel some people last week because I was at a follow up appointment and my doctor was like, hey, you can't leave. We have to do this right now. So I called her and I was like, I can't work today. And she just like, took care of it. So that's, that's been awesome.

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Dr. Amy Marschall  [00:19:10]:

I mean, depending on your setup, not everybody uses an admin. It just reached the point that with the volume of inquiries I was getting, it was taking up too much of my day to be calling people back and answering emails and answering messages and answering just everything. It was, it was just, it was too much of my time. So I did hire her to, to do or partner with them. I guess technically they employ her and I just pay an invoice every month. I think I should have done that sooner as well. I was hesitant because I was like, oh, but that's, then you have to pay them. And I'm like, okay, but what's the value of that time that I'm getting back? Basically?

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Michael Fulwiler [00:19:50]:

Yeah, we've talked about that idea on the show a lot, that it can feel expensive to hire accounting firm like heard. Right. Or hire an admin. But when you think about the time that you're spending and what your time is worth, and not even just your time, but also your energy, if you're exhausted from going back and forth on email or doing billing, the fact that you are able to outsource that, get your time and energy back to reinvest in your business or not is completely worth it.

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Dr. Amy Marschall  [00:20:24]:

Or just have the time. Yeah, yeah.

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Michael Fulwiler [00:20:28]:

You have mentioned this. You also do assessments and evaluations. Would love to dig into how you got into that. Maybe we just start there. How did you start offering assessments?

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Dr. Amy Marschall  [00:20:40]:

That's kind of always been something I've been doing, like the whole time. I mean, depending on where you are, scopes of practice and training and everything, oftentimes it has to be a psychologist doing the assessments. But that was a big part of my training. And, you know, a lot of my supervisors coming through grad school said this is kind of the main thing that you can do as a psychologist that you couldn't do with another degree as a therapist. So why are you spending an extra three years in training and why are you spending this much money? Well, really it's because you're getting this extra training in, I mean, in the assessment specifically. So, you know, why not do that? So, and my, you know, my internship and my postdoc were very assessment heavy, so I just kind of kept doing that.

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Michael Fulwiler [00:21:29]:

And what kind of assessments or evaluations do you offer?

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Dr. Amy Marschall  [00:21:32]:

So primarily, the majority of the assessments I do are ADHD and autism. Initially, I was kids and adolescents, but not a lot of people do that for adults. So I really quickly, again, rural mental health adults were calling and saying, I can't find anyone who does this. Is there any chance? So I did more training, and I got some consultation, and I figured it out basically. And so now I do it a lot for adults because a lot of us were still not great at identifying either in kids, but a lot of us grew up in the eighties and nineties and early two thousands when we were even worse about identifying any of that. And so we've got people realizing now and wanting support, going back to school, needing accommodations, etcetera. So I kind of fell into that. I do some others as well.

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Dr. Amy Marschall  [00:22:22]:

There's a, in South Dakota, there's some disability services that you have to have certain psych assessments on file in order to receive the services. So I do those evaluations for the state, I do assessments, you know, for the VA. I do some, like, eligibility for disability services, basically, and then just whatever people call about. If I'm like, yeah, that seems doable to me. Once in a while I'll do something for, like, an IEP. But often the school wants their psychologist doing it, so I'll do those for when the school has refused to do the testing, but said, we'll accept an external report. Then the parents call me.

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Michael Fulwiler [00:23:03]:

Have you seen an increase in demand for assessment services, specifically around ADHD, from people talking more about ADHD on social media? I know there's people who are, like, self diagnosing themselves on TikTok. Has that impacted your practice?

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Dr. Amy Marschall  [00:23:22]:

Well, for my practice, I noticed the uptick in 2020, and what I have attributed that to, and I don't know how much this has been actually researched, but what I noticed was a lot of people went home and stress level went up, and they realized that they were basically at their limit with masking, and they finally couldn't do it anymore. So that was kind of the trigger for, okay, something is not right here. What do I need to change? And so that's when they started reaching out. There's a lot of nuance. So for when it comes to, like, self identifying, self diagnosing accuracy is not 100%, but it is pretty high, and especially for autism. There's a study that came out in February that found that first of all, the rads are, which you can take for free on embrace autism, that they were finding that people who scored above that cutoff score were almost always autistic based on more testing. So, you know, and evaluations are expensive and it's hard to find a provider who is competent to work with adults and you can pay for a whole assessment and still they die. You know, the evaluator can get it wrong.

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Dr. Amy Marschall  [00:24:38]:

That happened to me. I had to be evaluated twice because they got stuff wrong in the first one. So, you know, I can see why someone might not have the option to get, like, officially diagnosed. I've heard stories of people in custody battles and their ex will talk to the judge and say, you know, they're autistic and I'm not. Therefore I'm the more fit parent. And then the judge awards custody. There's states that put you on a list if autism is in your official medical record. New Hampshire got rid of theirs, but there are still, I think, seven states that still require you to be put on a government list if you're autistic, which is ridiculous, and there are countries you can't immigrate to if autism's in your medical record.

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Dr. Amy Marschall  [00:25:24]:

So some people understandably are like, these traits resonate. I do all these things, I feel all these things, I experience all these things. I'm not going to go pay $3,000 for someone to maybe accurately perceive me. And now I, you know, hey, now I've lost my kids or now I'm on a government list or my, my visa has been revoked because I wanted to have it be official. So. But on the other hand, if you don't have the official diagnosis, you can't use it to request an accommodation, get support at school, get support in your workplace, apply for disability benefits. So really self identifying doesn't take anything away because you can't access any of the very, very limited services unless it's actually in your medical record. And there's lots of reasons why people don't want it in their medical record.

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Dr. Amy Marschall  [00:26:18]:

So that's why I support that. But I see a lot of people who, you know, especially with the push to go back to the office who said, you know, I came home and I unmasked and I realized how miserable I was at the office and how much that was hurting me. I would like the accommodation to keep working from home, and you can't get that unless you have it, you know, in your record.

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Michael Fulwiler [00:26:38]:

So that's a great point. You mentioned that testing is expensive.

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Dr. Amy Marschall  [00:26:42]:

Yes.

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Michael Fulwiler [00:26:42]:

You threw out a number there, $3,000. Are you able to share what you charge for testing versus therapy?

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Dr. Amy Marschall  [00:26:49]:

Varies a little bit. What I do, and this actually, it depends on. Depends on where you are, because I'm also a registered psychologist in New Zealand, and the organization I work with through New Zealand and helped with the founding and funding and all that we have, this is how much it costs and it's just like a set. And then we do sliding scale for low income. But in the US I just have an hourly rate. And so if the report writing takes me 2 hours, I turned you for 2 hours. If it takes me 3 hours, I charge you for 3 hours. Mine usually end up in about the $900 to $1,200 range.

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Dr. Amy Marschall  [00:27:27]:

And actually I was able to recently lower it a little bit because one of the insurance companies that had been giving me just issue after issue and forcing me to call and spend hours on the phone arguing about why they should pay for the service, in theory, what they're supposed to do for their customer who gives them money. And I finally said, I'm not dealing with you anymore. And I decredentially. And that freed up several hours a week of my time, because when it comes to authorization, that's not something I can outsource to my admin. I have to do that because they need me to defend why the services were necessary. So I, as the provider, have to do that. And it freed up so much in my time that I lowered my cash rates.

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Michael Fulwiler [00:28:10]:

So are you able to take insurance then, for testing?

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Dr. Amy Marschall  [00:28:14]:

Yes, so I can bill out of network. Not everybody has out of network benefits, but I take a couple of insurances that are local. In South Dakota, there's two hospital systems in Sioux Falls, Sanford and Avara. Actually, I was at an event. Sanford gave me a branded water bottle, but I'm not plugging them. It's just, it's a big water bottle, so I like it. But each of those systems has an insurance company, so I am. I accept both of those insurances.

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Dr. Amy Marschall  [00:28:50]:

I don't know if it's because they're small, but they just don't give me a lot of trouble. They don't require prior authorization. They don't make me call and call and call to get paid. I've just generally had good experiences with them. And then I'm a Medicare provider, and then I takes out the code of Medicaid, and I would take more Medicaid, but they won't let me.

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Michael Fulwiler [00:29:11]:

You said that you're also licensed in New Zealand.

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Dr. Amy Marschall  [00:29:14]:

Yes.

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Michael Fulwiler [00:29:14]:

Which is interesting. How did that happen?

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Dr. Amy Marschall  [00:29:17]:

So I had my honeymoon there in 2019, and we loved it. We went to Australia and New Zealand, and we loved it. We loved New Zealand. We loved Auckland in particular, and we both had job offers in Auckland in March of 2020. And, yeah, they were originally locked down for three weeks. So they said, send your stuff, apply for everything, and then in three weeks, when we come back, we'll process it. So I applied, and I'd applied to be registered, and then it was not three weeks. It was much longer than that.

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Dr. Amy Marschall  [00:29:54]:

And then I kind of. I had to let go of the job offer because I couldn't get my registration approved. I couldn't get a visa to be allowed to work over there. So my husband and I had to let those jobs go. And then, like, a year later, I got an email that said, hey, we've approved your registration. You can practice here now. So. Well.

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Dr. Amy Marschall  [00:30:16]:

And I was supposed to go back, but then my doctor told me not to fly because of my medical stuff. But the day that everything it went down was when I was supposed to fly out, and that flight got canceled. So every time I try to go back to New Zealand, there is a worldwide event that, like, shuts down all the travel. So I think I should just work remotely.

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Michael Fulwiler [00:30:38]:

Yeah, it sounds like it.

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Dr. Amy Marschall  [00:30:41]:

Yeah.

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Michael Fulwiler [00:30:42]:

Going back to testing. I just have one more question there, then I'd love to move on. How do you think about the balance between testing and therapy in your own practice, and what does that split?

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Dr. Amy Marschall  [00:30:53]:

Sure. So I have leaned more on testing just because there are fewer people who can do testing, and it's easier to find people to refer to for therapy. So because there are more therapists, more different licensures that can do therapy, there's kind of. There's just less of a shortage, basically, versus, like, testing, there's fewer people that I can refer to.

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Michael Fulwiler [00:31:17]:

Are you interested in growing your practice into a group practice? Have you been approached by other therapists, interns, people seeking supervision?

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Dr. Amy Marschall  [00:31:27]:

I have been, but I don't really want to add supervision to the things that I'm doing. And, I mean, I do that with change for better. So, like, I do some supervision and some oversight. Like, I'm the clinical director, so I'm not really interested in doing that for my own practice.

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Michael Fulwiler [00:31:43]:

So that makes sense. I want to jump to training. So you also offer training through Pessi. How did you get into that?

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Dr. Amy Marschall  [00:31:53]:

So with continuing education, when everything locked down, I noticed that a lot of the therapists that I network with that a lot of my colleagues who work with kids were having a really hard time doing telehealth with their child clients. And, I mean, I don't want to say the transition was easy, but I was finding all kinds of stuff that seemed to work really well. So, and I was looking for, like, what education do I need to be offering this service? And I wasn't really finding a whole lot. There was a little bit, I took a course with Liana Lowenstein. I think it was through the learning edge or something like that, that she does telehealth with kids. And that was a really great course, really helpful. But I was looking and I noticed that Pessi didn't have anything for telehealth with kids. But, you know, not to, not to flood them or inundate them, but they will accept a pitch from anybody.

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Dr. Amy Marschall  [00:32:50]:

You fill out the form on their website, and they will, I'm not saying that they'll automatically platform you, but they're like every, you know, we're always looking for speakers. Fill out the form. So I, I did, and they said, you're right. We don't have anything for telehealth with kids. Let's do that. So that kind of got me in the door. They're very thorough, and it's kind of slow moving. So I got a little bit frustrated with some of the things that I wanted to do because I was like, I want an ADHD brain.

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Dr. Amy Marschall  [00:33:19]:

I want to do this. I want to do this today. And they're like, all right, we'll get back to you in nine months. Yeah, like we're looking at, I'm doing something on supporting autistic adults who are experiencing burnout. And they're like, yes, we're scheduling December. And I'm like, what do you mean you're scheduling December? And I get that they're doing a lot of stuff. They book things out. But I was like, I want to go.

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Dr. Amy Marschall  [00:33:43]:

I want to do this. So I've done with some other organizations as well who want people who have that experience. Like, who have you taught with before? And I said, oh, I've taught with Pessi. So I got in that way. And I've taught with spring health, the telehealth certification Institute, a couple others. I have to go back and look at my resume. But what I found was that you can just make CE courses as long as you have the approval from the governing body. So I just went to APA and I said, how do you decide? And they said that they don't approve courses, they approve organizations, and anybody can apply to be a sponsor for continuing education through the American Psychological association.

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Dr. Amy Marschall  [00:34:35]:

So I just did that, which I didn't just do that. It was a. Oh, my God, the process. But I got it approved. So now I can create. And then I have not employees, but I have, like, partners, other psychologists who review. Anytime I create a course, they oversee and they make sure that it's up to the standards. And then, actually, I've got a coming up soon I just sent to APA.

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Dr. Amy Marschall  [00:35:01]:

Here's. Here's what I created. Here's what I've been doing. Here's how many people have taken each of my courses, and then I can go on my own timeline, because I just make it.

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Michael Fulwiler [00:35:11]:

Yeah. I love that you saw this opportunity. No one was really creating continuing education around telehealth for kids so that you just became that person. And now I imagine you've developed thought leadership and expertise around this topic. I'm sure you're invited to speak about it and talk about it and write about it.

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Dr. Amy Marschall  [00:35:33]:

I've got two books on telehealth with kids, and then I've done a whole bunch of other talks on other things related to telehealth. I've done, like, telehealth and psychological assessments, accurate diagnostics in telehealth. That was the Telehealth certification institute. I've done a few telehealth talks with spring health, and then in my own practice, I've got, or under my own sponsorship, I've got a general telehealth for therapists, telehealth techniques for children, telehealth and safety concerns. And then I think I have to look at my list again. But then I also with, with my own, was that I wanted to do more on, like, the neurodiversity affirming mental health care. So I've made a few of those as well, mostly focused on adhd and autism, just because that's both my training and my lived experience. Neurodivergence is everybody who's not under the neurotypical umbrella, and that includes psychotic disorders, mood disorders, other neurological conditions like epilepsy, traumatic brain injury.

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Dr. Amy Marschall  [00:36:42]:

It's a pretty big range, and I can't be an expert on all of it. So I speak about, like, this is relevant to a lot of people, and my knowledge is mostly adhd and autism. So I have that focus, but also that just, this isn't just, this isn't just this group. It's a lot of people.

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Michael Fulwiler [00:36:59]:

Right. As someone who is autistic and has ADHD, how does that impact you as a business owner and what are some of the things that you do to help manage that?

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Dr. Amy Marschall  [00:37:09]:

Yeah, I do have to keep an eye on my own burnout stuff because I don't really have a brake pedal. I just kind of have the gas pedal. So it is hard to slow down and it is hard to say no to opportunities. So I try to have boundaries around that. I am pretty firm about. I don't take like, people will be like, oh, can we do, you know, can we do just a quick 15 minutes call? I just want to pick your brain. And I'm like, all right, for $200, I will do that. First of all, that's good because I have bills.

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Dr. Amy Marschall  [00:37:42]:

But second of all, it shuts down. Like a lot of the, oh, don't you just want, you know, let's just talk. No, right.

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Michael Fulwiler [00:37:51]:

I was going to ask that question as well, something we've talked about at length. I posted about it recently on Twitter and LinkedIn today, actually, that as helping professionals, people have this expectation, I think, of therapists, that they'll do free labor. And so for folks who are listening, who get asked to do free labor, what would your advice be for them? And kind of what is your typical response?

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Dr. Amy Marschall  [00:38:20]:

One of the people I want to help is me, and she lives in my house and she insists on eating every single day. So I'm. Yeah, like, yeah, I want to help people, but my unpaid time, my unpaid work time goes to, I do a certain amount of pro bono clinical work. And that right now is focused in New Zealand with a change for better. And our hope is to grow that organization to be international. But basically, I ran the numbers and it was, it was a little bit ago that I ran the numbers. So this is not going to be accurate as of today. But earlier this year, I calculated that I had done the equivalent of $40,000 of clinical work.

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Dr. Amy Marschall  [00:39:05]:

Like, this is what the going rate for this would be that I was able to provide at just doing psychological assessments and people would pay for essentially the overhead so that I wasn't losing money on those assessments. And there were a few, honestly, that we went into the red for to be able to make it work for people. So when your $10 million app, you know, valued at ten or even 100 million, I had a company that was valuated at over a billion dollars. Reach out and want to pick my brain for free because don't you want to help people? I do want to help people. And the people who I help, who don't pay me are the clients who can't afford to pay the going rate for an assessment, who can't afford to pay my rate for an assessment, which is lower than the going rate because I do try to be accessible. So you know how I can afford to do $40,000 of pro bono work? Because when the hundred million dollar app wants to pick my brain, they're going to pay me. And that money subsidizes my ability to help people who actually can't afford to pay me. Because if your app is valued at $100 million, you could pay my rate.

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Dr. Amy Marschall  [00:40:17]:

You're choosing not to. And.

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Michael Fulwiler [00:40:19]:

Right.

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Dr. Amy Marschall  [00:40:21]:

Honestly, I just. I tell them that when they're like, don't you want to help people? This is just a quick call. I will. I will google the name of the company, and if the information is public, I'll be like, here's how much funding you pulled. I. You can pay me for my time. You can afford to, because here's how much funding you have. And.

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Dr. Amy Marschall  [00:40:39]:

And I'll just. Honestly, I'll just be an asshole about it. I'm sorry. I don't know if I'm allowed to say asshole in here, but definitely, yeah. And I put it. And I put it on my website. I'm like, here is. Here's what my rate is.

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Dr. Amy Marschall  [00:40:51]:

By contacting me, you indicate that you understand that rate. It doesn't eliminate the people demanding my unpaid time, but it does reduce it significantly. Also. This is maybe, you know, I'm not saying you have to do this. This might be too snarky for some people, but my website now lists a haggle fee. So if you contact me and you don't immediately agree to my rate, my rate goes up. Because you have made me haggle with you. And I've never had someone pay the haggle fee.

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Dr. Amy Marschall  [00:41:20]:

It's really more just to show you, like, no, I said, this is my boundary. We're not.

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Michael Fulwiler [00:41:29]:

I love that.

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Dr. Amy Marschall  [00:41:29]:

Yeah, I had that someone, and, yeah, someone reached out recently about something, and they're like, how much would this be? And I wrote back, based on what you're describing, that would be $500 for that consultation. And they said, we don't have $500. We have 150. Can you please do it for 150? And I wrote back, per my website, these rates are non negotiable. The rate is now dollar 550.

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Michael Fulwiler [00:41:50]:

I love that. Yeah. I imagine also that there are companies who are willing to pay in that initial request to pick. Your brain could turn into a consulting opportunity. Have you consulted with these types of companies as well?

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Dr. Amy Marschall  [00:42:05]:

Oh, yeah. So I have, actually. So I don't know if you. This is a fidget. It's magnets, and it's really cool. And these guys, like, emailed me randomly and said, we need to consult someone about a new product that we're putting together. And I wrote back and I was like, I assume you saw my rate on my website? And they said, yes, of course. What email address can we PayPal that to you? And we had a great talk.

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Dr. Amy Marschall  [00:42:31]:

And I actually, they had a. They had a question about a study that they're putting together. And I said, I'm not a researcher, but I have a friend who is. I put them in touch with her. And, you know, I got a. I got free magnets, but I did a blog post about the magnets. And, you know, they got, they got, like, I hope they feel like they got value out of it. I mean, I'm still talking about that.

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Dr. Amy Marschall  [00:42:53]:

But they were like, of course we're going to pay you for your time. Like, that's not even a question. And, you know, now they get plugged all the time because I love those things and I just use them, you know, just at my desk, I'll be. And, you know, I'll have. I had a contact from this company called Grace. G r A Y c e. But they do, they're often an employment benefit, I think. I don't want to misspeak on what they do, but what I help them with, like, psychologists tips on their social media, they do, like, question and answer.

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Dr. Amy Marschall  [00:43:28]:

Like, we did one that was, if you have a child and you suspect they may be neurodivergent, what next steps? Like, ask a psychologist what next steps you want to do stuff like that. So they get that resource that they get to have as part of what they're able to offer, and then they compensate me fairly for my time.

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Michael Fulwiler [00:43:48]:

I can understand why therapists do feel some guilt around saying no, because inherently, most therapists do want to help people. But I think what I'm hearing you say is that if you don't have those boundaries and you say yes to those types of requests, one, it just puts you at risk of burnout because you're just taking on more labor. But it's also, we've talked about this on the show as well. It's like, if you're taking on these unpaid opportunities, they really can be distractions from opportunities that could be paid or could be work that you actually want to be doing because you only have so much time in the day.

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Dr. Amy Marschall  [00:44:31]:

Yeah, well. And you only have so much money to run your business. And if I didn't have such firm boundaries around tech companies that are worth enough money that they could pay me if they wanted to, I wouldn't be able to do the low cost adhd and autism evaluations. I wouldn't financially be able to afford to cut my clients the breaks that I've been able to cut them. And especially my low income clients who are struggling to make ends meet and need this diagnosis to get the support that they need in order to thrive in their lives, are more important than $100 million app. The $100 million app can subsidize the client, not the other way around.

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Michael Fulwiler [00:45:20]:

That makes sense. As you think about your practice and your business today, with all these things that you're doing, what are some of the challenges that you're facing and how are you thinking about them?

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Dr. Amy Marschall  [00:45:32]:

Sure. Well, right now I'm trying to medically recover so that I can be back at 100% for work. So that's kind of the main one. It is hard. I want to be able to see everybody and, you know, I also can't, like, there aren't enough hours in the day, so having solid people to refer to when it's like, I can't do this, but here's somebody that I know will do it. Well, basically is a bit of a challenge. And then I guess, as I'm with the, with the continuing education, Apa has a lot of fees around that. So I would love to, because I know that a lot of us are nothing paid what we're worth.

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Dr. Amy Marschall  [00:46:15]:

So I would love to be able to create some continuing ed that's just free for people. Like, you can just have your ces, but I've got to make back what I put into it before I can do that.

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Michael Fulwiler [00:46:27]:

Yeah, well, it sounds like getting approved for Medicare in other states also.

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Dr. Amy Marschall  [00:46:31]:

Oh, that would be nice. Yeah. Although Medicaid in other states, honestly, that's a bit of a sliding scale thing as well, because Medicaid does not reimburse at a sustainable rate. That's a. That's a whole other problem. But that's. That's something I want to do because, again, I want to be accessible and I want to be able. Someone who has Medicaid, I want to be able to say, yes, you can get the service you need, because I accept the way that you're, you know, I can accept the payer who is.

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Dr. Amy Marschall  [00:46:58]:

Who oversees and make sure, you know, you can't find someone who takes your payer. I want to be able to take that payer. So I have a much higher threshold of tolerance for Medicaid than I do for the private insurance companies just because those are the people who just simply, I can't do a payment plan. I can't save up, I can't whatever. Like, I can't get this service unless you can take Medicaid. So it's an accessibility thing. And you can't bill Medicaid out of network, but you can bill the other insurances out of network a lot of the time. So that's, again, that's accessibility.

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Dr. Amy Marschall  [00:47:35]:

I want people to get the services they need.

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Michael Fulwiler [00:47:37]:

I said Medicare, they're not Medicaid. So that was my.

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Dr. Amy Marschall  [00:47:40]:

Medicare is different. Medicare is a federal program, so technically I can take Medicare from most states. There are a couple of plans that get a little bit like, there's one in New York that's basically, it's Medicare, but it's through Medicaid. So I can't take it because I'm not in New York. But I've seen Medicare clients in other states just. Well, and they also don't reimburse at a sustainable rate. So I can, you know, again, I consult with tech companies and I charge them a consultation fee, and then I can afford to take more Medicare clients because I'm taking the hit on what I'll get for this assessment, but I have other revenue streams.

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Michael Fulwiler [00:48:21]:

We're coming to the end of our conversation. Would love to wrap this up with a final question. What's one thing that you want therapists who are listening to take away from this? I know that we've talked about a lot of different topics, but if there's just one takeaway, I mean, I'd say.

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Dr. Amy Marschall  [00:48:39]:

That charging for your time, don't take those free consultations. When I respond to those, I get a little. I don't know if mean is the right word, but my goal, when someone is like, how dare you not work for free? My goal is to give them a response that they will be embarrassed to say that to somebody else. If you're having trouble saying no for yourself, say no for the rest of us. Because every time somebody says yes to that request, it reinforces that that's an okay thing to ask somebody, and it's not. So if we all said, why would you ask somebody that eventually I would like them to be shamed into not making those requests anymore.

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Michael Fulwiler [00:49:20]:

Thank you, Doctor Amy, so much for coming on. For folks who want to connect with you, where can they find you?

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Dr. Amy Marschall  [00:49:26]:

Well, resiliency, mental health is my blog and that kind of connects to everything else. I'm on Twitter and bluesky as Doctor Amy Seide. I'm on Mastodon, Dramy, Sidey, Ohi social, and then I'm Facebook doctor Amy Marshall. I am not on LinkedIn because LinkedIn sucks. Great.

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Michael Fulwiler [00:49:50]:

Well, we'll post those links in the show notes. We won't put LinkedIn on there. Thank you so much again for coming on. This has been great.

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Dr. Amy Marschall  [00:49:58]:

Yeah.

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Michael Fulwiler [00:50:00]:

Thanks for listening to this episode of Heard Business School brought to you by Heard, the financial back office. For therapists, visit the Heard resource hub at joinheard.com to support you in your journey as a private practice owner owner. And don't forget to subscribe on YouTube, Apple, Spotify or wherever you get your podcasts. We'll see you in the next class.