You have a full caseload. You have a waitlist. You are turning away referrals every week. The logic feels obvious: hire someone, expand the practice, serve more clients, generate more revenue. It is the right instinct. And it is also the moment when most group practices make their first serious operational mistake.
The mistake is not hiring. The mistake is hiring before the infrastructure exists to support a hire.
This distinction matters because it changes what you do first. Most practice owners post a job listing and figure out the systems afterward. The ones who build sustainable group practices figure out the systems first — and then post the listing.
What infrastructure actually means
When practice owners talk about being ready to hire, they usually mean they have enough clients to keep an associate busy. That is necessary but nowhere near sufficient.
Being ready to hire means you have a written employment agreement reviewed by a healthcare attorney. It means you have a documented onboarding process. It means you have a billing system that does not depend on you personally running it. It means you have thought through supervision requirements under your state’s licensing regulations, liability coverage for the new hire, and — critically — what happens if the hire does not work out.
That last one is the one practitioners most consistently skip. It is also the one that creates the most expensive problems.
A substantial share of group practice owners report that their first hire created significantly more administrative burden than they anticipated, particularly around onboarding, billing workflows, and supervision documentation. This is not because hiring is inherently complicated. It is because the systems that make hiring manageable were not in place before the hire started.
The APA Services practice management guidance identifies legal, ethical, and administrative issues faced when supervising others — record keeping, boundaries, informed consent, scheduling, and performance evaluation — as the areas that require the most preparation before a hire begins. These are not things you figure out after someone starts. They are things you document before you make an offer.
The agreement you skip is the one that costs you
The single most common legal problem in group practice is an employment agreement that was never written, or was written without legal review, or was borrowed from a template that did not account for healthcare-specific requirements.
The issues that emerge from these agreements are predictable. Unclear non-solicitation clauses that do not adequately protect the practice if the associate leaves and takes clients. Ambiguous ownership of client relationships that creates disputes about who the clients belong to. Undefined termination procedures that make it legally complicated to end a relationship that is not working.
These problems are cheap to solve before a hire. They are expensive — sometimes devastating — to solve after a dispute has begun.
Non-solicitation agreements in particular require careful drafting in a healthcare context. They need to balance the practice’s legitimate interest in protecting client relationships against the associate’s right to practice. Getting this wrong in either direction creates problems. Getting it right requires someone who understands both employment law and healthcare regulations — which is why the standard recommendation from healthcare attorneys and the AMA is to have the agreement reviewed by a specialist, not a general practice attorney.
Spend the money on the healthcare attorney before you spend it on the first salary. The conversation with the attorney costs a few hundred dollars. The dispute without one can cost tens of thousands.
— Diane Osei, Business & Therapy
The AMA’s guidance on physician employment contracts and the AMA Guiding Principles for Physicians Entering into Employment are both valuable reference points, even for non-physician mental health practitioners. The core principles — written agreement, legal review, clear termination procedures — apply across licensure types. MedCentral’s guidance on employment contracts for mental health clinicians makes this explicit: it is essential to have agreements reviewed by an attorney familiar with both contracts and healthcare-specific labor laws.
What the onboarding process actually covers
An employment agreement is the legal foundation. Onboarding is the operational one. And most group practices do not have an onboarding process — they have a first week of improvisation that looks different for every hire.
A documented onboarding process covers at minimum: how the new clinician gets set up in your EHR system, how they access scheduling, how their billing is processed (and by whom), what the supervision schedule looks like and how it is documented, what your practice’s policies are on client communication and crisis management, and what happens in the first 30, 60, and 90 days.
This sounds like a lot of documentation. It is. It is also the difference between a new hire who feels supported and a new hire who feels like they are figuring out a new job and a new system at the same time — which is a recipe for early turnover.
Write the onboarding process before you hire. Then use the first hire to test and improve it. By the second hire, it should run without you managing every step.
Build the system before you need it
The practitioners who scale group practices successfully share one characteristic that shows up consistently: they built systems before they needed them. The onboarding process existed before the first hire started. The billing workflow was documented before the second clinician joined. The supervision structure was established before it was legally required.
This feels like over-preparation when you are a solo practitioner with a waiting list and a sense of urgency about expanding. It is actually the minimum viable infrastructure for a sustainable practice. The practices that skip it pay for it — in turnover, in administrative chaos, in legal disputes, and in the burnout that comes from running a group practice on solo-practitioner systems.
What to do this week
If you are thinking about your first hire in the next six months, do these three things now — not after you have identified a candidate:
Engage a healthcare attorney. Have them review or draft an employment agreement template specific to your state and your licensure context. Ask them specifically about non-solicitation clauses, client relationship ownership, and termination procedures. The AMA’s guidance on finding a healthcare lawyer is a useful starting point for understanding what to look for in that specialist.
Document your current intake and billing process. Write it out in enough detail that someone else could follow it without asking you questions. If you cannot document it clearly, it is not ready to be handed off. This documentation becomes the foundation of your onboarding process.
Identify your supervision structure. Research your state’s requirements for licensed associates versus provisionally licensed clinicians, determine who will provide supervision and how it will be documented, and get that structure in writing before you make any offers.
The hire will still be challenging. It will be significantly less challenging if the foundation is in place before they start. And the foundation takes longer to build than you think it will.
Start now.
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