Counseling Services Inquiry Form
By completing this form, you are requesting to schedule an initial 20 minute video consultation with Brittany of Hautz Counseling. This form supports the therapist and you in determining whether our services may meet your needs. Thank you for taking the time so that we can better support you!

*If you are experiencing a mental health emergency, please seek immediate help. Hautz Counseling is not a crisis intervention service provider. Please call the Crisis Lifeline at 988, or the Suicide Prevention Lifeline at 800-273-8255, or you can text HOME to the Crisis Text Line at 741741. These services are free and confidential.*
Email *
About Brittany
Brittany Hautz (she/her) is a Licensed Professional Counselor who works with her fellow LBGTQIA+ queer community, and women who have a history of trauma, and are looking to strengthen their boundaries, feel empowered in communications, and heal their relationship with Self, and important others. Brittany is Certified in an advanced trauma treatment modality called Brainspotting. This is a specialty, brain-body approach that goes beyond traditional talk therapy. If this sounds like what you're looking for, then please answer the questions below, thank you!
Service Locations
Due to state licensing laws, all clients must be physically in the state of PA when completing a TeleHealth appointment. In-Person services are offered in Fox Chapel in the Pittsburgh area. Our office is on the second floor of the office building; 8 steps from floor 1 to 2.
Email Address:
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Name you go by and your pronouns: *
First and Last Administrative Name: *
How did you hear about Hautz Counseling? *
If you selected that you were referred by someone, please provide their name. (N/A if not applicable).

Note that if it is a current or past client, know that I will not be able to confirm or deny my relationship with them.
 *
Are you aware of any conflicts of interest prior to beginning therapy with me? 

(such as a close friend, roommate, or family member is a client of mine)
 *
What are your top 3 priorities in seeking treatment at this time? What do you want to address first?
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Please select which option below sounds most like what you are seeking in regards to services.

Note that I have more information about Brainspotting on my website if you have questions.
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Please check all boxes that apply to you presently (now or within the past 3 months) OR in the past (more than 3 months ago). If the item never has applied to you, please select that box. 

Note, these are not immediately disqualifying of outpatient care, and simply will be further discussed at the consult so that we can better recommend the right services to meet your needs. Thank you!
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Past
Present
Never
Substance misuse or abuse and/or addiction
Disordered eating habits and/or eating disorder
Extreme paranoia, or active psychotic symptoms
Self injurious behaviors and/or self harm
Thoughts to end life and/or suicidal ideation
Attempted to harm self and/or end life
Thoughts to harm others, or end someone else's life
Hospitalized for mental health
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