Family of Origin Form Book An Appointment Family of Origin Please fill out this form to the best of your ability. If at any time you feel re-traumatized, you should stop immediately and it will be addressed in session. Be sure to hit 'submit' when you are finished.Name* First Last 1. Identify your major caregivers:Caregiver Name Caregiver Relationship Caregiver Name Caregiver Relationship Caregiver Name Caregiver Relationship Caregiver Name Caregiver Relationship Caregiver Name Caregiver Relationship 2. 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)sibling AgeDescriptive Noun or Adjective sibling AgeDescriptive Noun or Adjective sibling AgeDescriptive Noun or Adjective sibling AgeDescriptive Noun or Adjective sibling AgeDescriptive Noun or Adjective Number of children in your family:Your rank in birth order:If you were adopted, at what age were you adopted?3. List other adults who were involved in your childhood. Use a noun or adjective to describe each person.Adult/Relationship Description Adult/Relationship Description Adult/Relationship Description Adult/Relationship Description Adult/Relationship Description Parental Information4. 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. 5. Is your father living? Yes No If your father is deceased, how old were you at the time of her death?If the person you are identifying as your father is not your biological father, identify your relationship to him. 6. If your parents were living during your childhood, were they: separated divorced living together What age were you when they separated?What age were you when they divorced?If your parents are living, what is their current marital status? Married Separated Divorced Re-married 7. What were/are the educational levels and occupations of your parents?Mother: Education Mother: Occupation Father: Education Father: Occupation Early Family Relationships8. Describe the physical, financial, and emotional situation of your parents at the time of your birth or adoption.9. Describe the relationship that existed between your mother and father at the time of your birth or adoption.10. Describe how your mother felt at the time of your birth or adoption.Describe how your father felt at the time of your birth or adoption.11. Describe the relationship that existed between your mother and father during your childhood.Childhood Memories and Parental Relationships12. 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 again yourself as a child being in the physical presence of your father: List nouns and adjectives to describe your mother:PositiveNegativeList nouns and adjectives to describe your father:PositiveNegativeChildhood Memories of Your Mother13. Describe the happiest time you remember with your mother.14. Describe the worst time you remember with your mother.15. What did you want from your mother that you never received or she never did for you? (Example: That she would love me as I was.)16. As a child, what did you do to get approval from your mother?Childhood Memories of Your Father17. Describe the happiest time you remember with your father.18. Describe the worst time you remember with your father.19. 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)20. As a child, what did you do to get approval from your father?Childhood21. Describe your earliest memory. What was your age at the time?22. When you think of yourself as a child, how old are you?23. Describe yourself as a child?24. Describe feelings you had as a child. These may include feelings such as being sad, mad, glad, or scared or feeling of shame, guilt, empty, and/or lonely.24. Describe feelings you had as a child. These may include feelings such as being sad, mad, glad, or scared or feeling of shame, guilt, empty, and/or lonely.25. What was your favorite childhood story? This can include stories such as a fairly tale, book, television show or movie. Describe the theme of your favorite story and how you related to each of the main characters.26. Identify the people you felt close to in your childhood.27. As a child, was it easy or difficult to make friends? Why do you feel it was easy or difficult making friends?28. As a child, did you have nicknames? Yes No If you had nicknames, what were your nicknames and who gave them to you?Current Relationship With Major Caregivers29. Describe the relationship you have with your mother today.Describe the relationship you have with your father today.30. If you had other major caregivers, identify the major caregiver(s) and describe your current relationship(s).Reflections31. Reflect on your childhood and your life today. In what ways would you and your life be different today if you had had functional parents?Please hit 'Submit' when you are done
