Sample Genogram Format

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

Death = X (can give cause of death: CA, ALC,

Index Person (IP): HA, car accident, Suicide, etc.)

Marriage (give date) Living together

(Husband on left, wife on right): relationship or liaison

m. 67 (give date) 79

Marital separation (give date): Divorce (give date):

s 78 d. 82

Children: List in birth order Adopted or foster children

beginning with oldest on left: 70 72 75 ---------

I put names inside squares/circles

Fraternal Identical Pregnancy:

twins: twins:

Spontaneous Induced Stillbirth:

abortion: abortion:

o X Ab 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: _________

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