|
Completed By:
|
|
|
Child's Name:
|
|
|
|
E-Mail:
|
|
|
Child's Date of Birth:
|
|
(mm/dd/yyyy)
|
| |
| Mother's Family of Origin: |
Describe your mother and father (positive and negative).
|
| |
How did your parents show affection to each other and their children?
|
| |
How did your parents handle disagreements and conflicts; what were
their main methods of discipline?
|
| |
How many siblings do you have and what role did each sibling play
in the family?
|
| |
Discuss history of alcohol or drug abuse; physical, emotional or
sexual abuse; mental or emotional illnesses in the family; how was each
issue dealt with?
|
| |
| Mother's Medical History: |
List any current/past illnesses/injuries that has impacted you or
your family.
|
| |
| Mother's Marital History: |
Describe your current marriage (positive and negative);
i.e. intimacy, communication, problem-solving, togetherness.
|
| |
Write a brief description of any previous marriage(s).
|
| |
| Mother's Current Family: |
List your children and give a brief description of each child.
|
| |
What are your main methods of discipline and how effective have they been?
|
| |
What concerns do you have with any other member of the family?
|
| |
How large of a role (if any) does religion play in your family?
|
| |
Describe positive attributes, strengths and support systems in your current
family?
|
| |
| |
| Father's Family of Origin: |
Describe your mother and father (positive and negative).
|
| |
How did your parents show affection to each other and their children?
|
| |
How did your parents handle disagreements and conflicts; what were
their main methods of discipline?
|
| |
How many siblings do you have and what role did each sibling play
in the family?
|
| |
Discuss history of alcohol or drug abuse; physical, emotional or
sexual abuse; mental or emotional illnesses in the family; how was each
issue dealt with?
|
| |
| Father's Medical History: |
List any current/past illnesses/injuries that has impacted you or
your family.
|
| |
| Father's Marital History: |
Describe your current marriage (positive and negative);
i.e. intimacy, communication, problem-solving, togetherness.
|
| |
Write a brief description of any previous marriage(s).
|
| |
| Father's Current Family: |
List your children and give a brief description of each child.
|
| |
What are your main methods of discipline and how effective have they been?
|
| |
What concerns do you have with any other member of the family?
|
| |
How large of a role (if any) does religion play in your family?
|
| |
Describe positive attributes, strengths and support systems in your current
family?
|
| |
| |
|
