Performance Max is Google's all-in-one campaign. A practice supplies the money and the creative; Google chooses, ad by ad, whether a counseling message lands in a results page, a YouTube break or a Maps listing. For a retailer with a product feed and a customer list, it can find buyers no keyword list would reach.
A therapy practice comes to it with two disadvantages. Google won't let it use the data most advertisers feed the campaign, and a typical practice books only a handful of new clients a month, which gives it little to learn from. Neither one rules Performance Max out. Together they set the timing, and the setup has to keep Performance Max from cannibalizing the counseling searches the earlier chapters worked so hard to win.
Eleven of the 12 Therapy Sites We Read Fall Under Two of Google's Sensitive Ad Categories, Not Just Health
Google keeps a list of sensitive interest categories, topics where it limits how advertisers can target people. Mental health is named outright. Google's own example list for the Health category spells out counseling for depression, anxiety and addiction. A separate category, Relationship hardships, lists "Family or relationship counseling services" and "Bereavement products or services."
Most practices touch more than one. We went back through the 12 Louisville-area practice websites from the research for this guide and checked the services each one lists against Google's categories, counting only what appears on the site's own service list:
- Couples, family or grief counseling (Relationship hardships): 11 of 12
- Trauma or PTSD work (Abuse and trauma, in our reading; Google's examples name shelters and victim services, not therapy): 9 of 12
- LGBTQ+-affirming therapy (Sexual orientation and Transgender identification, again our reading): 3 of 12
- Medication management or ketamine-assisted therapy (Restricted drug terms, our reading for ketamine): 3 of 12
Counting Health, 9 of the 12 sites fall into at least three categories.
Every one of those categories carries the same restriction: audiences the advertiser builds itself are off the table. Google's not-supported list for these categories includes Customer Match (uploading a client list), your data segments (people who visited your site), lookalike segments and audience expansion. What remains is Google's own predefined audiences: in-market segments, affinity, life events and demographics.
Custom segments, which many advertisers build from competitor websites or search terms, get stuck too. Per Google's footnote, a custom segment tied to a sensitive landing page can only serve in Display campaigns, to non-sensitive audiences or by page content. Any other campaign using one with a sensitive landing page won't be eligible to serve, and that includes Performance Max.
Uploading a client list would be a bad idea anyway. The list itself is health information (Chapter 1). The policy just makes the decision for you.
Performance Max Has Nothing to Learn Until Your Search Ads Bring In About 30 Real Inquiries a Month
With no client list and no site visitors to model, Performance Max learns mostly from one thing: the conversions you tell it count. That's why the order matters.
For the first months, the Search account does the learning. The exact-match campaign (Chapter 6) books sessions from searches you chose, and every attended first session goes back to Google by click ID (Chapter 1). Our rule, tied to Google's own target CPA guidance in Chapter 6: when the practice is logging roughly 30 qualified inquiries or attended first sessions a month, there's finally enough for Google's automated bidding to read. Performance Max needs that same footing, and in the therapy accounts we plan it usually comes after broad match has settled, around months six or seven.
Before that point, Performance Max has to guess. It can't see who books, and in a sensitive category it can't borrow audience data either. It finds whatever is cheapest to convert, and in our experience that is often a contact form from someone who never answers the callback.
The conversion goal is where most of that risk lives. Give Performance Max the same goal the Search account uses: a qualified inquiry at first, then an attended first session once the practice can send those back by click ID. Leave out page views, clicks on the phone number that never ring through and anything else that's easy to rack up. Google will chase whatever you call a conversion, at whatever volume it can find.
Search Themes Stand In for the Client List a Therapist Can't Upload
If a therapy practice can't tell Performance Max who its clients are, it can still tell it what they search for. That's what search themes are for. Google lets you add up to 25 per asset group, and it describes them as optional and "additive to what queries Performance Max would match you to using your URLs, assets, and more."
For a practice, the best themes come straight from the Search account's own results: the specialty searches that already book sessions, like "EMDR therapy near me," "couples counseling Louisville" or "therapist for teen anxiety." Each asset group gets the themes for its specialty, matched to that specialty's page from Chapter 4.
Leave out the themes that pull in the wrong stage of the search. Chapter 2 split symptom searches like "signs of depression" from searches for a therapist, and the same split applies here: a theme built on a symptom invites Performance Max to chase people who are still reading, not booking. Leave out the national-platform names too. A theme like "online therapy" puts a local practice in the same auctions as the biggest spenders in the category, which is where Chapter 7 said to walk away. A short list of specialty searches that already book is worth more than 25 themes picked from a brainstorm.
Search themes also protect the Search account. In the auction, a search theme ranks alongside a phrase or broad keyword, no higher. An exact-match keyword that's identical to the search beats Performance Max outright, per Google's own rules. So searches identical to your hand-bid exact-match keywords (Chapter 7) stay in the Search campaign. On anything your phrase or broad keywords also cover, the two campaigns compete on Ad Rank, which is why the themes should reach past what the Search account already covers.
Audience signals, the other way to guide Performance Max, are limited to Google's predefined segments for a therapy practice. They're hints, not targeting; Google says new signals can take up to two weeks to take effect. Treat them as a nudge and judge the campaign on first sessions, not on which signals you picked.
Performance Max Will Bid on People Googling Your Practice's Own Name Unless You Add a Brand Exclusion
People searching for the practice by name are the easiest conversions in the account, and Performance Max knows it. Leave the door open and Performance Max can show up on those name searches, then take credit for clients who were coming anyway.
Chapter 9 put the practice's name in its own small Search campaign. Performance Max needs to stay out of it. Brand exclusions do that: Google says they "keep your campaigns from serving for branded queries you want to avoid," and in Performance Max they cover Search, Shopping and YouTube search results. Brand exclusions work from Google's list of recognized brands, not typed-in keywords: add the practice to a brand list, and request it if Google's brand library doesn't have it yet. Google then matches misspellings and variants on its own. Clinicians' names go on the Performance Max negative keyword list instead.
Negative keywords now work in Performance Max too, at the campaign or account level. Add the same exclusions the Search account uses, starting with jobs and careers searches, national platform names and any crisis terms the practice can't answer in an ad (Chapter 5).
Every Line Google Writes for a Therapy Practice Is Still the Practice's Responsibility
Performance Max writes. It mixes your headlines and descriptions, builds new combinations, can pick landing pages with Final URL expansion, and can generate assets of its own. Google's help page is clear about who owns the result: "you remain responsible for reviewing and ensuring compliance and accuracy of landing page content, and all dynamically generated assets."
For a therapist, that responsibility has a second layer. The ACA asks counselors to make reasonable efforts to keep statements others make about them accurate, and the APA's code says psychologists "who engage others to create or place public statements that promote their professional practice" keep "professional responsibility for such statements." An auto-generated line promising results, or a landing page swap that sends a teen anxiety search to an adult medication page, belongs to the practice the moment it runs.
So the setup leans toward control. We give each asset group its specialty page, switch off text customization so Google isn't writing new claims, and turn Final URL expansion off until the campaign has a record, then test it with URL exclusions for the pages a search should never reach. We supply real photos and a short real video of the practice: the office, the waiting room, a clinician talking plainly about what a first session is like. Stock footage of a sad person staring out a window says nothing true about the practice. Then we read the asset and landing page reports every week, the same way Chapter 8 checks every ad line against its page.
None of this makes Performance Max a bad fit for therapy. For a group practice with several specialties and a steady stream of booked sessions, it can reach people on YouTube, Gmail and Discover the Search account never sees. It just has to come after the Search account has proved what a real client looks like.
Next: Mental Health Ads in Demand Gen Run Mostly on YouTube
Performance Max reaches people who are close to searching. Demand Gen reaches them earlier, mostly on YouTube, with the same audience limits. Chapter 11 covers what a therapy practice can run there and why video comes first.
For how first sessions reach Google by click ID, see Chapter 1; for exact match and broad match, Chapter 6; and for the brand campaign and launch settings, Chapter 9. Every chapter is on the guide home.
For a counseling group under our Google Ads management, Performance Max comes months after the launch, never with it. It arrives after the Search account has months of attended first sessions behind it, and a person reads every asset and landing page report each week.
