Mental health practices face no-show rates as high as 60%. Every missed appointment is lost revenue, wasted clinician time, and a patient not receiving care they need.
Standard reminder calls help. Live phone calls that reach patients produce no-show rates around 3%, compared to 24% for voicemail and 39% for no contact. But there's something that addresses the deeper causes of no-shows in mental health: getting patients to engage with their care before the appointment happens.
A patient who completes a PHQ-9 the day before their session isn't just providing clinical data. They've invested something. They've reflected on their symptoms. They're significantly more likely to show up.
Why mental health no-shows are different
Mental health treatment requires confronting difficult emotions. Patients may want to feel better but also dread the process. The morning of an appointment, avoidance can win.
Depression reduces motivation and energy. Anxiety makes leaving the house feel overwhelming. The very conditions being treated create barriers to treatment. Standard reminders only address forgetting. They don't address ambivalence, symptom barriers, or disconnection from care.
Patients who don't feel connected to their provider or invested in their treatment are more likely to skip. Unengaged patients are twice as likely to delay care and three times more likely to have unmet medical needs.
How pre-appointment surveys create commitment
When patients take an action related to their appointment, whether completing a survey or answering questions about their symptoms, they've invested something. Psychologically, this creates commitment. Skipping the appointment means that investment was wasted.
This isn't manipulation. It's the same principle that makes booking a non-refundable hotel room more likely to result in a trip than a fully refundable one. Behavioral economics research confirms that small actions create disproportionate commitment to follow-through.
Completing a survey also prompts patients to reflect on their symptoms. A patient who just rated their depression as a 16 on the PHQ-9 has reminded themselves why they're in treatment. The survey brings the purpose of the appointment back into focus.
When patients know their clinician will review their pre-appointment survey, the session becomes a conversation about something they've already contributed to. This shifts the appointment from "something I have to go to" to "something I'm participating in."
What the research shows
Reminder systems reduce no-shows, but engagement matters more than delivery method. A systematic review found that patients receiving appointment reminders showed a weighted mean relative reduction in non-attendance of 34% from baseline rates. But "reminder plus" interventions, where reminders were combined with additional engagement, outperformed simple reminders.
In mental health specifically, targeted text messages reduced no-show risk by 11%. One outpatient mental health clinic implementing automated engagement systems saw no-show rates drop from 18.55% to 7.01%.
The key finding: live calls create social obligation, but surveys create engagement with the content of care. Both mechanisms reduce no-shows, but surveys also improve session quality by providing pre-visit clinical data.
Designing effective pre-appointment surveys
Not all pre-appointment surveys reduce no-shows equally. For pre-appointment use, aim for 2-5 minutes of patient time:
- PHQ-9 alone: 9 questions, 2-3 minutes
- PHQ-9 + GAD-7: 16 questions, 4-5 minutes
- PHQ-2 + GAD-2 as quick check-in: 4 questions, 1 minute
Send surveys 24-48 hours before the appointment. That's far enough ahead that patients have time to complete it, close enough that the appointment feels imminent, and recent enough that responses reflect current status.
Frame surveys as clinically useful: "These questions help Dr. Smith understand how you've been feeling so your session can focus on what matters most to you." Patients should see why the questions matter. Generic satisfaction surveys don't create the same commitment as clinical assessments that clearly relate to their treatment.
Include a clear call to action: "Please complete this 3-minute check-in before your appointment tomorrow at 2 PM with Dr. Smith." Specify what to do, how long it takes, when the appointment is, and who they're seeing.
Handling non-completers
Patients who don't complete pre-appointment surveys are at higher risk for no-shows. If a patient doesn't complete the survey, that's a signal. They may not have seen the message, they may be ambivalent about attending, they may be struggling with symptoms, or technical problems may have prevented completion.
Send a reminder 12 hours after the initial survey request with a direct link. If still incomplete the morning of the appointment, a phone call from staff works as both a reminder and a chance to identify barriers. Ask about obstacles and offer to complete the survey over the phone if needed.
Track patterns. Some patients consistently don't complete surveys but always attend. Others consistently don't complete and frequently no-show. Adjust approach accordingly.
Adding barrier-identification questions
Beyond clinical assessments, consider: "Is there anything that might make it difficult for you to attend your appointment tomorrow?" with options for transportation challenges, schedule conflicts, feeling too unwell, or anxiety about the appointment.
Patients who select a barrier can be contacted proactively. This surfaces problems before they become no-shows.
For ongoing patients, "What's one thing you'd like to discuss or work on in tomorrow's session?" helps patients prepare mentally and creates additional investment.
Measuring impact
Before implementing, document baseline no-show rates overall, by provider, and by appointment type. Once surveys are live, track completion rates, time to completion, and, most importantly, no-show rates for patients who completed surveys versus those who didn't.
Based on research on engagement and attendance, a 20-40% reduction in no-shows is achievable. Patients completing surveys typically show 70-85% attendance. The effect is strongest for patients previously ambivalent about treatment.
Calculate ROI: (number of no-shows reduced) x (average appointment revenue) = recovered revenue. For most practices, even a 20% reduction produces returns that exceed implementation costs.
Making it work
Pre-appointment surveys work best as part of a broader engagement strategy. Reduce wait times between scheduling and first appointment, since long waits increase no-shows as motivation fades. Offer telehealth alternatives when in-person is difficult. Build relationship through consistent, prepared clinical encounters.
The goal isn't just to get patients through the door. It's to engage them in their care. Pre-appointment surveys do both: they improve attendance and they improve the quality of the sessions patients attend.