Intake Questionnaire - Guy Soucy Well-Being Specialist

Guy Soucy - Well-Being Specialist
Client Intake Questionnaire

1:1 Emotional Well-Being & Transformation Coaching

This form helps me understand your inner landscape, your current challenges, and the transformation you're seeking. Your answers will remain confidential and will guide the focus of our sessions.

🌐 www.guysoucy.ca
📩 guysoucy.coach@gmail.com
Section 1: Personal Information
Name*

First NameLast Name
Email*
example@example.com
Mobile Number (optional)

Country CodeArea CodePhone Number
Country*
Country time zone*
Zoom Call (link will be sent to your email)MS TeamsWhatsApp (enter mobile number above)Other
Are there any scheduling limitations I should be aware of?
Absolutely!!Nope
Where did you hear from me?*
Section 2: Your Current Situation
What brought you to coaching at this time?*
What is the main challenge or area of life you're struggling with right now?*
How long have you been experiencing this challenge?*
Section 3: Emotional & Nervous System Patterns
CalmAnxiousOverwhelmedNumb / Shut downStressedStableUp and downOther
What situations, environments, or interactions tend to trigger stress or emotional activation in you?*
Fight (irritation, anger, defensiveness)Flight (restlessness, overthinking, wanting to escape)Freeze (shutdown, difficulty thinking, numbness)Fawn (people-pleasing, over-accommodating)Physical symptoms (tight chest, stomach, heart rate, tension, rashes)Other
What currently helps ou regulate your nervous system or calm down?*
Section 4: Your Life & Environment
EmotionsRelationshipsFamily dynamicsBoundaries / People PleasingStress & BurnoutConfidenceWork / CareerLife TransitionSelf-WorthOverthinkingPhysical EnergyOther
What areas of your life feel stable or supportive right now?*
Section 5: Your Goals & Desired Transformation
CalmConfidenceClarityPeaceEmotional FreedomMotivationSelf-LoveDirectionBoundariesEnergyJoyInner StrenghtStabilityOther
What results do you hope to achieve through our work together?*
If you could change ONE thing in the next 30 days, what would it be?*
Section 6: Past Work, Tools & Growth Experience
NoYes
If YES: What worked well for you? What didn't
NoYes
If YES or in the past: What type of support did you/are you receiving and how often?
NoYesPrefer not to say
If YES: Anything important you feel comfortable sharing that would help me support you safely?
NoYesPrefer not to say
If YES: Please list anything relevant
Breathing exercisesMeditationSomatic PracticesJournalingSelf-Hypnosis / HypnotherapyEFT / TappingHaveningEnergy HealingPhysical ActivityTherapyNoneOther
How often do you use these tools?
Section 7: Commitment & Expectations
On a scale of 1-10, how committed are you to your personal growth right now?*
Call, Supportive GuidanceGentle AccountabilityFirm AcountabilityDeep Emotional ProcessingPractical Tools and StructureNervous System RegulationMindset ReframingA Safe Space to Express OpenlyClear Direction and StrategiesOther
Is there anything important you want me to know before we begin?
When our work together is complete, how do you want to feel?*
🌿 Coaching Disclaimer & Agreement

Please read the following carefully:
Coaching is a collaborative, supportive process focused on emotional regulation, personal growth, mindset, and nervous-system resilience.

My role as a coach is to guide, support, and empower you using tools such as emotional regulation, nervous system techniques, somatic awareness, and mindset reframing.

Coaching is NOT a substitute for psychotherapy, mental health treatment, or medical care.

This means:
- I do not diagnose or treat mental health conditions
- I do not provide psychotherapy
- Coaching should not be used in place of professional mental health support when needed
- If you are experiencing severe psychological distress, crisis, or symptoms requiring medical/clinical intervention, I may recommend or require referral to a licensed mental health professional
If you are currently working with a therapist, psychologist, psychiatrist, or any mental health professional, it is recommended that you inform them that you are also participating in coaching.

This helps ensure that your overall support system is aligned and consistent.

You agree to seek professional medical, psychological, or psychiatric support when necessary, and to inform me of any conditions that may impact your coaching process.

By signing below, you confirm that you understand the nature of coaching, the difference between coaching and therapy, and that you take full responsibility for your emotional, mental, and physical wellbeing during the coaching process.
Signature*

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Date*

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Please verify that you are human*
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Guy Soucy - Well-Being Specialist

Client Intake Questionnaire

1:1 Emotional Well-Being & Transformation Coaching

Section 1: Personal Information

Section 2: Your Current Situation

Section 3: Emotional & Nervous System Patterns

Section 4: Your Life & Environment

Section 5: Your Goals & Desired Transformation

Section 6: Past Work, Tools & Growth Experience

Section 7: Commitment & Expectations

🌿 Coaching Disclaimer & Agreement