If you are interested in booking an appointment or an initial free 15-minute video consultation with me, please fill out the form below. I will reach out to you as soon as possible.

If you are looking for my office address, you can visit the Arrival Instructions page.

Inquiry Topic

Inquiry topic

• Individual Psychotherapy
• Relationship / Couples Therapy

Primary Client

Full name *

First

Last

Preferred name

Pronouns

Email *

Phone number *

Date of birth *

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Your Partner's Information

Partner's full name *

First

Last

Partner's preferred name

Partner's pronouns

Partner's date of birth *

Partner's email *

Partner's phone number *

Is your partner's address the same as yours?

• Yes
• No

Partner's address

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Fee Schedule and Policies

I understand that this practice does not accept insurance. *

• Yes
• No

I understand that I will incur $250.00 for the first appointment and $200.00 for each follow-up appointment. *

• Yes
• No

You can access a Good Faith Estimate of your treatment costs at this link: https://shaysavilla.com/good-faith-estimates/.

I understand that this practice will not be billing insurance for me and I will only receive a receipt for services. *

• Yes
• No

I understand I would be responsible for submitting claims to my insurance plan if I would like to use my out-of-network benefits. *

• Yes
• No

You can learn more about how to use your out-of-network benefits at this link: https://shaysavilla.com/out-of-network-benefits/.

Fee and Policy Acknowledgement *

• I agree with your scheduling and cancellation policies.

You can read my Fees and Policies at this link: https://shaysavilla.com/fees/. Please note that I only accept self-pay clients at this time but you may be able to use your out-of-network benefits.

Scheduling Preferences

Preferred modality *

• In Person
• Virtual

Mondays

• Afternoon
• Evening

Tuesdays

• Afternoon
• Evening

Wednesday

• Afternoon
• Evening

Thursdays

• Afternoon
• Evening

Fridays

• Afternoon
• Evening

Your goals

Client Message

Visual Text

Residency acknowledgement *

• I will be physically located within Illinois or Washington, D.C. during all of my sessions.

Please note that I am only able to see clients who reside in Illinois and Washington, D.C. at this time due to clinical licensing requirements.

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