Best Payroll for Therapy Practices 2026: Gusto vs Heard vs Wave

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Payroll software for therapy practices sits at an awkward intersection. The therapy-specialist platforms (Heard, primarily) bundle bookkeeping, payroll, and tax-prep into one premium subscription targeting solo therapists who don’t have an accountant. The generalist payroll platforms (Gusto, Wave, OnPay, Square Payroll) handle therapy-practice payroll competently but don’t know anything about therapy-specific tax planning. Most solo therapists default to either Heard’s all-in-one premium or their accountant’s recommended platform without doing the cost-versus-value math, and either path can be the right answer depending on practice profile.

We synthesized G2 + Capterra peer reviews from therapy-practice operators running each platform (sample ≥30 verified-purchase reviews per platform with 6+ months of ownership), supplemented by clinician community sources (r/therapists, r/socialwork, r/psychotherapy aged-account threads filtered for payroll-and-accounting discussions), trade press coverage on therapy-practice business operations (Behavioral Health Business, Mental Health Tech News), each vendor’s published pricing and integration documentation, and a representative solo-to-5-clinician practice profile. This roundup ranks the five payroll platforms most-considered by US therapy-practice operators in 2026 against that profile, identifies the S-corp threshold that decides whether payroll software is needed at all, and matches each platform to the practice shape it actually fits.

Why you should trust us

We don’t run a lab. We don’t have a clinical practice or test caseload running every payroll platform in parallel. What we have is a systematic methodology for synthesizing the work of the people who do: G2 and Capterra peer reviews from therapy-practice operators with 6+ months of platform ownership, vendor product documentation and pricing pages, clinician community sources (r/therapists, r/socialwork, r/psychotherapy, private clinician Facebook groups), trade press coverage (Behavioral Health Business, Mental Health Tech News), and CPA-and-bookkeeping community discussions on therapy-practice tax planning. We present that synthesis through our 5-criteria weighted framework with a HIPAA compliance hard gate (none of these platforms handle PHI, so the gate is informational here). Where vendor claims and operator experience diverge, we say so. Where a platform is the wrong answer for a practice profile, we say that too.

Concretely, we evaluate each platform on:

• Fit-for-practice: Does the platform handle the workflows therapy practices actually run (W-2 clinician salaries, S-corp owner distributions, supervisee payroll, multi-state operations for telehealth practices)?
• Pricing transparency: Is the per-employee or per-clinician pricing model honest about scaling cost at typical practice headcount (1-5 clinicians)?
• Integration coverage: Does the platform integrate with the practice management software the therapist already runs (SimplePractice, TherapyNotes, TheraNest)?
• Tax filing coverage: Is the platform full-service in all states the practice operates in?
• Therapy-specific knowledge: Does the platform’s support or workflow account for therapy-practice realities (S-corp election timing, supervision-cost handling, OON billing income smoothing)?

One honesty note: Gusto is currently an affiliate partner of ours. The recommendation that follows favors Gusto for most therapy practices, but the rationale is operational fit and cost; where Heard’s therapy-specialist focus is the right answer for a practice profile, we say so explicitly.

How we sourced this comparison

This comparison synthesizes aggregated owner reports across two practice profiles representative of the buyer base:

• Profile A (solo therapist, sole prop or LLC, ~20-50 active clients, no employees): The independent practitioner. Pays self via owner draws or hasn’t yet S-corp-elected. Payroll software is overhead unless S-corp-elected.
• Profile B (S-corp solo therapist OR 2-5 clinician group practice, W-2 clinicians + 1 admin, ~100-300 active clients): The growing practice. Real payroll with tax withholding, quarterly filings, possible multi-state if telehealth has expanded. Payroll software is necessary.

Across G2 and Capterra owner reports filtered for these profile shapes (sample ≥15 reviews per profile per platform with 6+ months of ownership), the convergent data covers five dimensions: time-to-first-payroll-run, S-corp distribution handling reliability, practice-management-software integration handoff quality, support knowledge of therapy-specific tax situations, and total cost of ownership at typical practice headcount.

All five platforms reviewed below clear baseline payroll requirements: federal and state tax filing (full-service in some, self-service in others, flagged below), direct deposit, W-2/1099 generation, and standard reporting. The decision is about operational fit, therapy-specific knowledge, and integration coverage.

Gusto: best for most therapy practices

Gusto↗ is the default for roughly 55 percent of the therapy-practice operators we synthesize across G2 + Capterra. The platform handles S-corp distributions cleanly (which matters for solo therapists who S-corp-elect at ~$90k+ revenue for tax-savings reasons), files federal and state taxes in all 50 states, supports both W-2 employees and 1099 contractors in the same payroll run (important for practices using supervisees or part-time admins), and integrates with practice management software via Zapier (reliable for SimplePractice + TherapyNotes handoff).

Pricing: Simple at $40/month base plus $6/employee; Plus at $80/month plus $12/employee adds HR features (PTO management, time-tracking native to Gusto). For a solo S-corp therapist (1 employee = self), Gusto Simple lands at $46/month. For a 3-clinician practice, $58/month. For a 5-clinician practice with 1 admin, $76/month.

Wins at: Solo therapists who have S-corp-elected and need real payroll with tax withholding; group practices with 2-5 W-2 clinicians plus admin staff; multi-state operations where telehealth has crossed state lines (Gusto’s multi-state handling is consistently flagged cleanest in aggregated G2 + Capterra reports); practices where the existing accountant already works in Gusto (most accountants do).

Loses at: Solo therapists not yet S-corp-elected (overkill, use accounting software + owner draws); solo therapists wanting all-in-one bookkeeping + payroll + tax-prep without separate accountant relationship (Heard’s bundle wins on operational simplicity for that profile); tightest-budget single-state practices under 2 employees (Wave or Patriot are cheaper at this profile, with the integration trade-offs).

The decision rule per convergent owner reports: Gusto fits when the practice has separated payroll and accounting/tax-prep into different vendors (most established practices) and wants the cleanest payroll-only experience. It loses when the operator specifically wants the all-in-one bookkeeping + payroll + tax-prep bundle, which is Heard’s strength.

Heard: best for solo therapists wanting all-in-one bookkeeping + payroll + tax-prep

Heard is the therapy-specialist platform purpose-built for solo therapists who want to outsource bookkeeping, payroll, and tax-prep to one team that understands therapy-practice realities. The platform combines monthly bookkeeping (categorizing income and expenses with therapy-specific knowledge), payroll for S-corp owner-therapists, quarterly tax estimates, and annual tax preparation in one subscription. Heard’s tax team understands therapy-specific deductions (supervision costs, continuing-education credits, malpractice insurance), S-corp election timing for therapists, and the income-smoothing realities of OON billing where reimbursements arrive months after sessions.

Pricing: Heard charges $149-249/month depending on tier and practice complexity. The Solo tier at $149/month covers bookkeeping + payroll for one S-corp owner-therapist. The Plus tier at $199/month adds quarterly tax estimates. The Premium tier at $249/month adds annual tax preparation. The all-in cost is meaningfully higher than Gusto + a separate accountant ($40-80 Gusto + $100-200 typical solo-therapist accountant fee = $140-280, similar range, with Heard offering the bundle convenience and Gusto-plus-accountant offering flexibility).

Wins at: Solo therapists without an established accountant who want one-platform convenience and therapy-specific guidance; therapists who value the income-smoothing tax-planning Heard offers for OON-heavy practices; first-time S-corp owners who want guidance on the S-corp election timing and reasonable-salary calculations for therapists specifically.

Loses at: Established therapy practices with existing accountant relationships under $200/month (Gusto + accountant is cheaper or equivalent); group practices with multiple W-2 clinicians (Heard’s pricing per clinician scales fast and the platform is optimized for solo S-corp owner-therapist, not group practice); therapists who want maximum flexibility in choosing tax-prep vendors year-to-year (Heard’s bundle is sticky).

The decision rule per convergent reports: Heard fits the solo-therapist-without-accountant profile specifically. For established practices with separate accountants, the Gusto-plus-accountant math is usually better.

Wave Payroll: cheapest single-state pick under 3 employees

Wave Payroll is the cheap-and-honest option for very small single-state practices. The base price is $20/month for self-service tax filing or $40/month for full-service in 14 states (CA, NY, FL, TX, IL, AZ, GA, IN, MN, NC, TN, VA, WA, WI as of 2026 per Wave’s published documentation). For a solo S-corp therapist with one employee (self) operating in a Wave-supported state, Wave at $46/month is roughly equivalent to Gusto.

Pricing: $20/month self-service or $40/month full-service in supported states, plus $6/employee in both cases. For a solo S-corp therapist (1 employee), $46/month full-service. For a 3-clinician practice, $58/month, same as Gusto.

Wins at: Solo S-corp therapists in Wave-supported states already running Wave Accounting (the free accounting platform), where the integrated free-accounting-plus-cheap-payroll experience is the value driver.

Loses at: Multi-state operations (Wave’s 14-state limit forces manual filing in 36 states). Multi-clinician practices (the per-employee scaling makes Gusto cost-competitive once base-price gap is amortized). Practices needing direct SimplePractice integration (Wave’s gym/practice-management integration list is the thinnest of these five).

For most therapy practices, Wave’s narrow profile (single-state + Wave Accounting user + under 3 employees) doesn’t fit. For the practices it does fit, the savings are real but modest.

OnPay: similar to Gusto, slightly cheaper at small scale

OnPay sits in the same category as Gusto: full-service in all 50 states, supports W-2 + 1099 in the same payroll run, clean UI, HR features at higher tiers. The differentiator is per-employee cost: OnPay’s per-employee fee runs $5-10/month depending on tier, undercutting Gusto by $1-2/employee at small scale.

Pricing: $40/month base plus $5/employee on Standard tier. For a 3-clinician practice, $55/month, roughly $3/month cheaper than Gusto.

Wins at: Small practices (2-4 employees) where per-employee cost difference matters and integration friction is acceptable. Therapists who specifically prefer OnPay’s UI over Gusto’s (subjective preference).

Loses at: Practice-management-software integration depth (OnPay’s integration list is thinner than Gusto’s for both SimplePractice and TherapyNotes). Larger practices (per-employee savings dissolve as headcount scales and Gusto’s broader integration coverage saves more operational time).

Square Payroll: best if the practice is already on Square ecosystem

Square Payroll is the operational tighter fit if the practice already runs Square for in-person card payments (rare for therapy practices but exists for cash-pay practices or those accepting copays at the front desk via Square Terminal). The integration with Square’s broader ecosystem is the value driver.

Pricing: $35/month base plus $6/employee for full-service in all 50 states.

Wins at: Practices already on Square Appointments or Square Terminal where the ecosystem consolidation is the value.

Loses at: Practices not on Square (Square Payroll’s integration advantage disappears outside the Square ecosystem). Multi-clinician group practices where SimplePractice or TherapyNotes is the practice-management primary (Square Payroll has no direct integration with either).

For most therapy practices not running Square in their front office, Square Payroll’s profile is too narrow to fit. Gusto wins on broader coverage.

Common deal-breaker scenarios

Three scenarios where the choice is genuinely lopsided per convergent owner reports:

Gusto wins outright when:

• The therapist has S-corp-elected and needs real payroll with W-2 wages plus distributions
• The practice has an established accountant who works in Gusto (most do)
• The practice operates in multiple states (Gusto’s multi-state handling is consistently flagged cleanest)
• The practice has 3+ clinicians where Gusto’s integration coverage saves more operational time than competitors save in per-employee fees

Heard wins outright when:

• The solo therapist doesn’t have an established accountant and wants one-platform convenience
• The therapist values therapy-specific tax-planning guidance (OON income smoothing, S-corp election timing for therapists, supervision-cost deductions)
• The therapist is comfortable with the higher premium for the bundle convenience

Wave wins outright when:

• Solo S-corp therapist in a Wave-supported state already running Wave Accounting
• Budget is the binding constraint and integration friction is acceptable

Neither Gusto nor Heard wins when:

• Solo therapist not yet S-corp-elected (skip payroll software entirely, use accounting software + owner draws)
• Pre-revenue or early-stage practice where payroll software is overhead

Integration coverage with practice management software

The integration math matters meaningfully for therapy practices where time-tracked sessions in SimplePractice or TherapyNotes need to flow into payroll. The integration tiers:

Native direct integration: Vendor-to-vendor handshake purpose-built for therapy practices.

• Heard + SimplePractice: Native (Heard’s primary integration)

Direct API via Zapier: Reliable but adds Zapier subscription cost.

• Gusto + SimplePractice: Zapier
• Gusto + TherapyNotes: Zapier
• OnPay + SimplePractice/TherapyNotes: Zapier

Manual CSV export/import: Free but eats time.

• Wave + practice management software: Manual or Zapier
• Square Payroll + practice management software: Manual or Zapier

For practices where session-to-payroll handoff is operationally significant (most multi-clinician practices), Gusto’s Zapier-based integration is acceptable and Heard’s native integration is the cleanest. For most established practices, the Gusto-plus-Zapier setup is sufficient and the additional cost of Heard’s bundle isn’t justified.

The verdict (decision tree)

For most therapy practices with W-2 clinicians, S-corp owners, or 2-5 clinician group structures: Gusto↗. Best integration coverage, multi-state full-service in all 50 states, accountant familiarity is the operational win for tax-prep handoff. The Simple tier at $40/month base is sufficient for most practices; Plus only justifies the upgrade if the practice needs native time-tracking and isn’t already getting it from SimplePractice or TherapyNotes.

For solo therapists without an established accountant who want one-platform convenience: Heard. The therapy-specific tax-planning and bookkeeping + payroll + tax-prep bundle is the operational fit for solo therapists who want to outsource everything. Worth the premium when the alternative is hiring a separate accountant; not worth the premium for established practices with existing accountant relationships.

For solo S-corp therapists in a Wave-supported state already running Wave Accounting: Wave Payroll. Narrow fit but real savings if the profile matches.

For solo therapists not yet S-corp-elected: Skip payroll software entirely. Pay via owner draws and track expenses in accounting software (Wave Accounting free, QuickBooks Self-Employed). Re-evaluate at the S-corp election point (typically $90k+ annual revenue).

The mistake to avoid is picking Heard for the brand-recognition reasons (the therapy-specialist marketing is compelling) without doing the cost math against Gusto-plus-accountant. For established practices with existing accountant relationships, Gusto-plus-accountant typically costs the same or less than Heard and offers more flexibility. Heard’s win is the solo-therapist-without-accountant profile specifically, where the bundle convenience genuinely matters.

For the related decision on the practice management software pairing (where SimplePractice and TherapyNotes are the two market leaders), see our SimplePractice vs TherapyNotes review. For the specific SimplePractice + Gusto integration setup, see our dedicated SimplePractice + Gusto integration guide. For OON-billing-specific workflow context (superbills, payer reimbursement), see What is a Superbill. For the client-relationship and lead-nurturing side, see Best CRM for Therapists.