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Intake Form

Client Intake Form & Packet Completion
At Canopy Doulas, our intake process is designed to ensure we understand your needs fully and provide you with the most personalized, attentive support possible.

This form allows us to gather important information about your preferences and needs. The more thorough and thoughtful your responses, the better we can advocate for you and tailor your care.

You may complete the Intake Form digitally for convenience.

If you prefer, you are also welcome to hand-fill the Intake Packet and submit it by scanning and emailing the completed documents to our team.

Please ensure all sections are completed before submission. Once received, a member of our team will review your information and follow up with next steps, including scheduling your consultation and confirming availability.

If you have any questions while completing your packet, we are here to help. Our goal is to make this process simple, clear, and supportive from the very beginning of your journey.

Contract of Services Complete Packet Online

Maternal First name*

Maternal Last Name*

Preferred Name

Birthday

Month

Day

Year

Phone*

Email*

Multi-line address

Country/Region*

Address*

Address - line 2*

City*

Zip / Postal code*

Marital Status*

Single

Married

Other

Father's First Name

Father's Last Name*

Preferred Name

Phone

Sperm Donor (IVF/IUI)

PROVIDER INFORMATION

Name

Phone

Address

Insurance Provider

Birthing Location*

HEALTH INFORMATION

Is this your first pregnancy?

Yes

No

If "NO", how many pregnancies have you had?

How Many Births Have You Had? (twins count as 1 birth, etc.)*

Have you had any preterm deliveries?*

Yes

No

If so, how many?*

List any medical conditions that the mother and/or father have or may have*

Have you had any previous surgeries or recent illnesses?*

List all medications or supplements, including herbal. *

List allergies (food/medication) for both the mother and the father*

Any alcohol, drug, or tobacco use by the mother or father? If so, please describe *

Have you been tested for STI's during pregnancy?*

List any pertinent family medical history (hypertension, stroke, birth defect, etc)*

When was your last menstrual period (LMP)?*

Length of menstrual period (i.e., 28 days, lasting 6 days)*

Have you used birth control or plan to use birth control after delivery?*

No

Yes

Do you plan to breastfeed?*

No

Yes

If you have delivered before, what type of delivery did you have and how long was your labor?*

Whom would you like to be present at your birth and during postpartum recovery?*

Are you currently working or plan to return to work after delivery?*

Yes

No

BIRTH PREFERENCES

Have you taken a tour of your designated place of delivery?*

Have you attended a childbirth and newborn education class? *

Do you desire to have an unmedicated birth?*

If you had a previous cesarean, do you desire to have a VBAC?*

Please choose which comfort measures you would like ot use during labor*

Therapeutic Music

Dancing/Swaying

Cold/Hot Packs

Massage

Accupressure Points

Aromatherapy

Birth Ball / Stool

Walking

Rebozo

Hydrotherapy

Breathing, Meditation & Visualizations

Dim Lighting

Other

Please list any cultural or religious beliefs you would like me to know, as well as any fears or dislikes you may have (e.g., essential oils, sensitive to physical touch, etc.).*

BIRTH & IMMEDIATE POSTPARTUM

Desired Birth Position*

Squatting or Stool

Standing

On your side

Hands and knees

In bed

Gentle cesarean

Desires for Immediate Postpartum*

Delayed cord clamping

Immediate skin-to-skin

Leave vernix on the baby

Surprise sex of the baby

Delay newborn examination

Parents want to birth the baby

Exclusively breastfeed/bodyfeed

Emergency donor milk

Formula/Bottle feeding

No eye ointment

No immunization

Take home the placenta

Please list other immediate postpartum wishes you would like to discuss

Yes, I give Canopy Doulas permission to contact me with transactional and promotional efforts

I have read the contract of services

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