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CLIENT INFORMATION
Date: _____________________________________
Name: _____________________________________
Age: ______________________________________
FAMILY OF ORIGIN
Identify your major caregivers
List the birth order of the children in your family. Use a noun or adjective to describe each person. Include yourself and deceased siblings. (Indicate if a sibling is deceased.)
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Description |
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Number of children in your family: ______________
Your rank in the birth order: ___________________
If you were adopted, at what age were you adopted? ________________
List other adults who were involved in your childhood. Use a noun or adjective to describe each person.
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Relationship |
Description |
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Parental 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.
Is your mother living? Yes ______ No ______
If your mother is deceased, how old were you at the time of her death? ________
If the person you are identifying as your mother is not your biological mother, identify your relationship to her.
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Is your father living? Yes ______ No ______
If your father is deceased, how old were you at the time of his death? ________
If the person you are identifying as your father is not your biological father, identify your relationship to him.
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If your parents were living during your childhood, were they
separated _______ divorced _______ living together _______
If they were separated or divorced, at what age were you when they
separated ________ divorced ________
If your parents are living, what is their current marital status? _______________
What were/are the educational levels and occupations of your parents?
Mother:
Education _____________________________________________________________
Occupation ____________________________________________________________
Father:
Education _____________________________________________________________
Occupation ____________________________________________________________
Early Family Relationships
Describe the physical, financial, and emotional situation of your parents at the time of your birth or adoption.
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Describe the relationship which existed between your mother and father at the time of your birth or adoption.
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Describe how your mother felt at the time of your birth or adoption.
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Describe how your father felt at the time of your birth or adoption.
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Describe the relationship which 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. After describing your mother, close your eyes and image yourself as a child being in the physical presence of your father.
List nouns and adjectives to describe your mother.
List nouns and adjectives to describe your father.
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