Family of Origin
Answer these questions drawing on your life from the ages of 0 - 17 years old
Client Full Name
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First Name
Last Name
Date Today
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Month
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Day
Year
Date
1) Identify your major caregivers (List "Name" and "Relationship")
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2) List the birth order of children in your family. Use a noun or adjective to describe each person. Include yourself and deceased siblings. (Indicated if a sibling is deceased.)
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3) Number of children in your family:
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4) Your rank in the birth order:
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5) If you were adopted, at what age where you adopted?
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6) List other adults who were involved in your childhood, their relationship to you and an adjective to describe each person.
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7) In what part of the world did you grow up? If more than one place, please list as many towns, countries, etc., as you can.
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Parental Information and Grandparent Information
In this form, the terms mother and father are used to indicate biological or adoptive parents and/or mother or father substitutes. For ease of reading and for identification purposes, the word mother and father are being used to describe all these relationships.
1) Is your mother living?
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Yes
No
2) If your mother is deceased, how old were you at the time of her death?
3) Cause of her death:
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4) If the person you are identifying as your mother is not your biological mother, identify your relationship to her.
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5) Is your father living?
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Yes
No
6) If your father is deceased, how old were you at the time of his death?
7) Cause of his death:
7) Cause of his death:
8) If the person you are identifying as your father is not your biological father, identify your relationship to him.
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9) If your parents were alive during your childhood, were they
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Separated
Living together
Divorced
10) If they were separated or divorced, at what age were you when they did so
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11) If your parents are living, what is their current marital status?
Separated
Divorced
Living together
12) Is your father single?
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Yes
No
13) Father is married to partner
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blanks
14) Is your mother single?
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Yes
No
15) Mother is married to partner
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blanks
16) MOTHER - What is the educational level of your mother? *AND* What is your mother's occupation(s)?
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17) How many siblings did your mother have?
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18) Where is she in the birth order?
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19) Where did she grow up?
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20) What was/is HER father’s occupation?
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21) List at least one character strength and character flaw for your maternal grandfather:
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22) What was/is her mother’s occupation?
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23) List at least one character strength and character flaw for your maternal grandmother:
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24) FATHER - What is the educational level of your father? *AND* What is your father's occupation(s)?
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25) How many siblings did your father have?
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26) Where is he in the birth order?
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27) What was/is HIS father’s occupation?
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28) List at least one character strength and character flaw for your paternal grandfather:
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29) What was/is HIS mother’s occupation?
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30) List at least one character strength and character flaw for your paternal grandmother:
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Early Family Relationships
1) Describe the physical, financial, and emotional situation of your parents at the time of your birth or adoption.
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2) Describe the relationship that existed between your mother and father at the time of your birth or adoption.
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3) Describe how your mother felt at the time of your birth or adoption.
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4) Describe how your father felt at the time of your birth or adoption.
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5) Describe the relationship that existed between your mother and father during your childhood.
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Childhood Memories and Parental Relationships
Before answering, close your eyes and image yourself as a child being in the physical presence of your mother. For example: What did it feel like to be in the same room, the car or sitting at a table with her? Talking with her? Having her car drive up to the house?
1) List nouns and adjectives to describe your mother. List positive, then negative.
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2) Describe the happiest time you remember with your mother.
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3) Describe the worst time you remember with your mother.
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4) What did you want from your mother that you never received or she never did for you? (Example: That she would love me just as I was.)
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5) As a child, what did you do to get approval from your mother?
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6) List nouns and adjectives to describe your father. List positive, then negative.
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7) Describe the happiest time you remember with your father.
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8) Describe the worst time you remember with your father.
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9) What did you want from your father that you never received or he never did for you? (Example: That he would support me in my decisions.)
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10) As a child, what did you do to get approval from your father?
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Childhood
1) Describe your earliest memory. What was your age at the time?
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2) When you think of yourself as a child, how old are you?
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3) Describe yourself as a child.
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4) If you were presented with unscripted free time as a child, what would have been your favorite things to do? (Draw upon elementary, middle and high school years collectively.)
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5) Describe feelings you had as a child. These may include feelings such as being sad, mad, glad, joy, or scared, feeling shame, guilt, empty and/or lonely.
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6) What was your favorite childhood story? This can include stories such as a fairy tale, book, television show, or movie.
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7) Identify the people you felt close to in your childhood.
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8) As a child, was it easy or difficult to make friends?
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9) Why do you feel that it was easy or difficult to make friends?
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10) As a child, did you ever have a nickname?
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11) If you had nicknames, what were your nicknames and who gave them to you?
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Current Relationship with Major Caregivers
1) Describe the relationship you have with your mother today.
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2) Describe the relationship you have with your father today.
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3) If you had other major caregivers, identify your major caregiver(s) and describe your current relationship(s).
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Reflections
1) Reflect on your childhood and your life today. In what ways do you imagine you and your life to be different today if you had had more functional parents?
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Submit
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