Assessment Form

This is the form I will send to you when we begin services.

Assessment Checklist

Check all the apply

  • Experience Bouts of Depression (mild)
  • Anxiety (social)
  • Isolation
  • low self esteem
  • nightmares at least 5 times per week
  • Boundary issues
  • Currently in an unhealthy relationship
  • Struggle with feeling overwhelmed around others
  • Pick up others behaviors as your own but go back to normal after you are alone
  • Randomly experience bodily sensations typically around people, animals or places. These sensations can be icky, unpleasant, emotional or dark in nature and there is no medical reasoning for this.
  • Just know things about others
  • Have premonitions
  • Vivid and active dreamer
  • Moods fluctuate throughout the day
  • Under the care of a physician for medical conditions
  • Under care of psychiatrist
  • Experience frequent physical fatigue not otherwise diagnosed as a medical condition
  • Experience frequent emotional fatigue
  • Attract emotionally draining people
  • Easily drained by human interaction
  • Pick up on others emotions or energy
  • Others tend to tell you their life story
  • Hate talking on the phone
  • Prefer to buy items online to shopping
  • Hate crowds
  • Experience random bouts of dizziness or fatigue not otherwise noted under medical condition
  • Highly sensitive
  • Prefer animals to people
  • In touch with Nature
  • Highly Spiritual or Religious
  • Introspective
  • See things others don’t see
  • Have conflict in relationships

Consent for payment, Purpose of Treatment & Confidentiality

First Name:
Last Name:
Please check box to indicate that you agree with terms stated below:
I agree to terms as stated: O
  1. I agree to complete my package within 60 days of purchase. If I do not, I forfeit my right to be refunded. It is my responsibility to contact The Christian Empath, any time, I need to reschedule a session or cancel a session. It is my responsibility to be as honest as I can with myself and the Christian Empath Coach; this ensures greatest outcome. I am voluntarily purchasing services on my own accord. I know that this process may bring up feelings and it is my responsibility to address that with The Christian Empath Coach. If I am not satisfied with services rendered, it is my responsibility to contact Amy at
  2. If life gets in the way, please contact Amy to make necessary accommodations. I know that my information via email and Skype is not 100% confidential but will do my best to protect my side of information from others around me.
  3. Confidentiality Policy:
 The code of ethics for counselors and the state laws regulating most kinds of counseling consider the personal information you discuss is confidential. This means we may not reveal any information about you to another person without your explicit permission. Therefore, all therapeutic communications, records, and contacts with professional and support staff, as well as between you and your counselor will be held in strict confidence. Information may be released, in accordance with Notice of Privacy Practice when:
  • Client signs a written release of information form indicating informed consent to such release
  • The client expresses serious intent to harm himself/herself or someone else, clearly identified
  • There is evidence or reasonable suspicion of abuse against a minor child, elderly person (sixty-five years or older), or dependent adult
  • A subpoena or other court order is received directing the disclosure of information.
Although we cannot guarantee it, we will endeavor to apprise you of all mandated disclosure. If you have any concerns or questions about this policy please discuss them with your counselor at the earliest possible time. We, the undersigned counselor and client, have read discussed together and fully understand this stated policy and agree to honor this policy.
Office use only: Original form August 2017 no revision in agreement with symptoms of being HSP and/or Empath and HIPPA compliant via other forms of communication. Amy Casale MS Christian Empath