This is Alex Baros Genogram. The genogram provides a graphic depiction of the family structure and history to the play therapist. The Intake form is a sample of the formats and symbols used to express various familial relationships.
The genogram is a popular way for determining who belongs in a family and what role essential family members play in relation to one another. A genogram resembles a family tree in structure, but it serves a very different purpose. A genogram contains information about family relationships and interactions, whereas a family tree merely shows lineage.