_LIFE SCRIPT



LIFE SCRIPTTERRY M. LEVY, PH.D., D.A.P.A., B.C.F.E.MICHAEL ORLANS, M.A., D.A.P.A., B.C.F.E.EVERGREEN PSYCHOTHERAPY CENTERATTACHMENT TREATMENT AND TRAINING INSTITUTE32065 Castle Court, Suite 325, Evergreen, Colorado 80439-3500303-674-4029 FAX: 303-674-4078 info@Life ScriptThis questionnaire is completed with the therapist. It is useful as a tool to facilitate discussion about family-of-origin issues.1. Where were you born, where did you grow up? 2. Who was living at home in your family when you were growing up?3. Write 4 to 6 adjectives that describe each sibling, from your perspective as a child.1 2 3 4. _______________1.1.1.1.2.2.2.2.3.3.3.3.4.4.4.4.5.5.5.5.6.6.6.6.Age ?Married?Children?Job?How do you get along with them now?4. Write 4 to 6 adjectives that describe each parent, from your perspective as a child. Mom: __________________ Age: Health?Dad: __________________ Age: Health?1.2.3.4.5.6.What did your mother do for work?What did your father do for work?Did you know your mother’s parents? Did you know your father’s parents?GF:GF:GM:GM:5. Why did your mother marry your father?(Best guess) Why did your father marry your mother?(Best guess) How did your parents handle: ConflictEmotionWho handled discipline of children? Who had the power in the relationship?6. Who were you closest to and why? Is this who you turned to for comfort?Were there any other adults with whom you were close as a child, or any other adults who were especially important to you?7. Write 4 to 6 adjectives that describe you As a child: Now:Health?11.2.2.3.3.4.4.5.5.6.6.8. What, if any, were the major/traumatic events that happened to you when you were a child? 9. a. What were the major messages your mother gave you about yourself and how to deal with life? b. What were the major messages your father gave you about yourself and how to deal with life? 10. a. Based on your observations of your mother, what did you learn from your mother about women? Women are… b. Based on your observations of your father, what did you learn from your father about men? Men are …11. Who was your favorite childhood hero or heroine?12. What was your favorite childhood story or fairy tale?13. What is your favorite holiday?14. Write 4 to 6 adjectives that describe each significant relationship you have had. 1 2 3 4. _______________1.1.1.1.2.2.2.2.3.3.3.3.4.4.4.4.5.5.5.5.6.6.6.6.How old were you? How long did it last?How did it end?15. Write 4 to 6 adjectives that describe each of your children.1 2 3 4. _______________age:age:age:age:1.1.1.1.2.2.2.2.3.3.3.3.4.4.4.4.5.5.5.5.6.6.6.6. 16. What would you write on the tombstone or as an epitaph for mother, father, (spouse), self?Mother:Father:Spouse:Self: ................
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