Name: _______________________________________________________      Date________________________
GENOGRAM:
 
 
 
 

Previous counseling?______________________________________________________________________________________________________________

Present medications:______________________________________________________________________________________________________________

Drug or alcohol history:_____________________________________________________________________________________________________________

Symptoms

Intrusive images

Negative thoughts:

"I'm not good enough" _____	"I'm unlovable"  _____	"I'm unimportant" _____	"I'm at fault"      _____
"I have no control"       _____	"I can't survive"  _____	"I might die"         _____	"I am hopeless" _____
"I am helpless              _____	"I am alone"      _____	"

Origin of negative thoughts:                  ________________________________  ___________________________________
 
                                                             ________________________________  ___________________________________

Top 8 emotional events in your life:     ________________________________  ___________________________________

                                                            ________________________________  ___________________________________

                                                            ________________________________  ___________________________________

                                                            ________________________________  ___________________________________

Complaints: (physical/relationship)      ________________________________  ___________________________________

                                                           ________________________________  ___________________________________

Significant people                             ________________________________  ___________________________________

                                                         ________________________________  ___________________________________

Desired goals:                                  ________________________________  ___________________________________

                                                        ________________________________  ___________________________________

                                                        ________________________________  ___________________________________

Dysfunctional behaviors, symptoms, and characteristics that need to be addressed.  Determine specific targets that need to be reprocessed. (Events that set the pathology in motion); present triggers that stimulate the dysfunctional material and positive behaviors and attitudes needed for future.