A. Family of Origin

1. Identify your major caregivers:

2. List the birth order of the children in your family. Include yourself and deceased siblings.

Number of children in your family: Your rank in birth order: If adopted, age at adoption:

3. List other adults involved in your childhood:

B. Parental Information

4. Is your mother living?

Yes No If deceased, age at death: If not biological mother, relationship:

5. Is your father living?

Yes No If deceased, age at death: If not biological father, relationship:

6. Parental marital status during your childhood:

Separated Divorced Living together Age when parents separated: Age when parents divorced: Current marital status of parents:

7. Parents' education and occupation:

Mother's Education: Mother's Occupation: Father's Education: Father's Occupation:

C. Early Family Relationships

8. Describe the situation of your parents at your birth/adoption: 9. Describe the relationship between your mother and father at that time: 10. Describe how your mother felt at that time: Describe how your father felt at that time: 11. Describe the relationship between your mother and father during your childhood:

D. Childhood Memories and Parental Relationships

12. List nouns and adjectives describing your mother:

Positive: Negative:

List nouns and adjectives describing your father:

Positive: Negative:

Family of Origin Questionnaire

A. Family of Origin

B. Parental Information

C. Early Family Relationships

D. Childhood Memories and Parental Relationships

Edmund Park