Welcome to your Systemic Roots Questionnaire • • • Dear client, The following questionnaire will help me prepare for your upcoming Systemic Roots session. Please take your time to carefully consider your answers. When in doubt: go with your gut instinct. Know that there are no right or wrong answers. Everybody's situation is different, and I am certainly not judging yours. The most important thing is for you to answer the questions truthfully – based on how you perceive things. This will help you get the most out of your session. Until we meet, Marleen IJsselmuiden Relationship with your biological parents RELATIONSHIP WITH YOUR (BIOLOGICAL) PARENTS Were you raised by your biological parents? Deselect Answer Yes, and my parents remained together when I was growing up Yes, but my parents were divorced or separated at some point No, because one of my parents passed away when I was young No, because one of my parents disappeared from view when I was young No, I was abandoned or separated from both of my parents, or both parents died at some point Other, namely... None If not your biological parents, then who raised you? You may skip this question if you were raised by your biological parents Are your biological parents still alive? Deselect Answer Yes, both of them My mother is still alive, my father has died My father is still alive, my mother has died No, both of them are dead I don't know None If yes, are you in touch with them? You may skip this question if both of your parents are deceased.Deselect Answer Yes, we have regular contact Yes, we have occasional contact No, I have ended all contact No, they no longer want anything to do with me Other, namely.... None Can you briefly describe the relationship you have or had with your parents? 1 out of 9 Relationship with your siblings RELATIONSHIP WITH YOUR SIBLINGS Do you have any biological brothers or sisters? Yes No, I'm an only child If yes, how many biological (half)brothers do you have? You may skip this question if you have no biological siblings If yes, how many biological (half)sisters do you have? You may skip this question if you have no biological siblings Are your biological brothers and/or sisters still alive? You may skip this question if you have no biological siblingsDeselect Answer Yes, all of them No, they have all died No, one or more have died, namely... None If yes, are you in touch with them? You may skip this question if you have no biological siblings Yes, we have regular contact Yes, we have occasional contact I am only in contact with some siblings, not all No, I have ended all contact No, they no longer want anything to do with me Other, namely Can you briefly describe the relationship you have with your siblings? You may skip this question if you have no biological siblings To your knowledge, did your mother have any... Miscarriage(s) Stillbirth(s) Abortion(s) None of the above I don't know 2 out of 9 Relationship with the rest of your family RELATIONSHIP WITH THE REST OF YOUR FAMILY Do you or did you have a notably close relationship with another member of your family, such as an aunt, uncle, grandpa or grandma? Deselect Answer No Yes, namely with... None Can you briefly describe the relationship you have with your family as a whole? 3 out of 9 Noteworthy family dynamics and/or events NOTEWORTHY FAMILY DYNAMICS AND/OR EVENTS To your knowledge, does any of the following apply to your family of origin: Chronic physical illness or handicap Mental illness (bipolar disorder, schizophrenia, narcissism, serious depression, etc.) Addiction (alcohol, drugs, gambling, sex, etc.) Premature death (illness, accident, suicide) Strict religion or sect Sexual abuse or incest Murder, war crimes or other serious offense Capture or imprisonment Persecution in the Holocaust or Japanese camps Emigration to another country Bankruptcy of a family business Financial exploitation or deceit Fighting over an inheritance Extramarital affair Discovery/suspicion of a family secret Miscarriage, stillbirth or abortion Adoption Shamed or suppressed LGBTQI+ identity Family member who is outcast or shunned Family member who went missing Family member who lives a very unusual life None of the above Other significant event or characteristic, namely... Please briefly explain the items that you've selected above 4 out of 9 Personal experience around family of origin PERSONAL EXPERIENCE AROUND FAMILY OF ORIGIN Please select the extent to which the following statements feel true to your experience with your family of origin I feel supported and like my family has my back Not at all true Totally true I feel accepted for the unique individual that I am by my family Not at all true Totally true I enjoy spending time with my family Not at all true Totally true I often feel forced to choose between different family members, as if I'm torn between them Not at all true Totally true I am very close to my mother and/or father, it is like we are best friends Not at all true Totally true I know that my parents did the best they could, even if it wasn't always what I hoped to receive from them Not at all true Totally true I feel alienated, as if I don't fully belong to my family Not at all true Totally true 5 out of 9 Chosen family CHOSEN FAMILY Are you currently in a romantic relationship? Yes, but it's still early days Yes, we are living together Yes, we are married or in a registered partnership Yes, but we choose to live apart together (LAT relationship) No, but I'm casually dating No, but I'd like to be No, and I'm not interested in a relationship right now Other, namely... If yes, can you briefly describe the quality and/or dynamics of your romantic relationship? If you are not currently in a romantic relationship, please describe the dynamics of (a) past romantic relationship(s). If no, can you briefly describe why you aren't in a romantic relationship? You may skip this question if you are currently in a romantic relationship Did you have a significant romantic relationship in the past that still lingers/affects you? No Yes, namely... Do you have any children? Deselect Answer Yes, I have (a) biological child/children Yes, I have (an) adopted child/children No, I don't want to have children right now No, I don't want to have children at all No, because I have difficulty getting pregnant Other, namely... None How many children do you have in total? Please detail the division in the textbox below, such as: 1 boy, 2 girls, or 1 adopted boy, 2 biological girls. If yes, can you briefly describe the quality and/or dynamics of the relationship you have with your children? You may skip this question if you don't have any children If no, can you briefly describe why you don't have any children? You may skip this question if you do have children 6 out of 9 Request for help REQUEST FOR HELP What compelled you to seek help? What are you hoping to get out of your Systemic Roots session? Do you personally experience: Big feelings that do not seem to fit your personal circumstances Episodes of depression and/or despair An overwhelming sense of having to accomplish something with your life A chronic physical disease or illness A sense of nothing in your life ever working out Feeling lost in life 7 out of 9 GENOGRAM GENOGRAM Please upload a graphic representation of your family tree, such as in the example below This will provide an easy reference as we talk through your family dynamics in your Systemic Roots session.You can find an editable format to design your family tree via this iCloud link: https://www.icloud.com/iclouddrive/091Vu3CLYdPgGwov_kPVk_iFw#DIY_Genogram_Grounding_GreenDownload the file, edit it according to your personal family tree, and then upload it as a PDF or JPEG.Alternatively, you could also sketch your genogram on a piece of paper, and then upload a picture of it.Although I have tried my best to include as many variations as possible in the editable PowerPoint format, every family situation is unique.Therefore, feel free to edit or adjust the document as you see fit.Bear in mind that the foundation of a genogram is your biological lineage first and foremost.Therefore, please try to keep it as clean as possible, and only include those non-biological figures that play a prominent role inside your family, such as an adopted child. Choose File Drag and Drop File Here or Browse 8 out of 9 Bonus: birth details BONUS: BIRTH DETAILS Although it is not strictly necessary to have your birth details in order to guide you through a Systemic Roots session, it does help me understand the dynamics that may be at play for you. If you wish, you can therefore provide me with your date, time and place of birth, so that I can have a peek at your natal horoscope and bodygraph. Needless to say, this data will be treated with the utmost confidentiality. What is your date of birth? What is your time of birth? Example: 17:21 hrs What is your place of birth? Example: The Hague, South-Holland, The Netherlands 9 out of 9 Thank you for completing the Systemic Roots Questionnaire. Please click the submit button to save your answers. Until we meet, Marleen IJsselmuiden Time's up
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