If you had or have children, please list in their birth order, including and indicating any still births, deaths, step siblings or adoptions with the birth order, and their parents
If you had any miscarriages, please list:
If you had any abortions, please list:
If you have any significant illnesses, please list:
If you have any addictions, please list:
If you feel there is anything else not covered you think is important to share, please list:
Please list in birth order, ALL brothers and sisters you had/have, including and indicating any step siblings or adoptions, and their parents.
Please list mother and father's names:
If so, please list anything about your lineage if known:
Please list, if known.
Please list maternal and paternal grandparents names if known:
If applicable to any grandparent, please list:
Please list anything you know about your family history. For example, the stories that have been passed down, who immigrated from where, how and when, if you know of any still births, abortions, miscarriages or death in child birth, mental illness, causes of death and when they died that you know of within your family. Do not worry if you do not know these things.
Please list any recurring or significant illness your parents, grandparents or siblings have or had. Please clearly list who and what illness they dealt with.
Did your parents, grandparents or siblings have any addictions? If so, please list who and what.
If you feel there is anything else not covered you think is important to share, please list:
Thank you! Your responses were received.
*Confidentiality: Information gathered in this form will be used solely for the purposes of your Family Constellation session and will be held in the strictest of confidence. Submission of this information goes directly to Shannon Carson at Shannon Carson Wellness.
