Genogram Format: Adapted from: Genograms in Family Assessment, by Monica McGoldrick

and Randy Gerson (N.Y.: Norton, 1985), pp. 154-5.

Male: Female: Birth date 43-75 Death date

Index Person (IP):

Death = X (can give cause of death: CA, ALC, HA, car accident, Suicide, etc.)

Marriage (give date) (Husband on left, wife on right): m. 67

Living together relationship or liaison (give date)

79

Marital separation (give date): s 78

Divorce (give date): d. 82

Children: List in birth order beginning with oldest on left: 70 I put names inside squares/circles

72

75

Adopted or ---------

foster children

Fraternal twins:

Identical twins:

Pregnancy:

Spontaneous abortion: o

Induced abortion: X Ab

Stillbirth:

SB

Members of current IP household (circle those living together with a dotted line):

Where changes in custody have occurred, please note:

Various lines indicate the type of relationship involved between persons: Very close relationship: Conflictual relationship:

Distant relationship:

Estrangement or cut off (give dates if possible):

Fused and conflictual:

_________