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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