Delta
Professions

Mental health & psychology

Psychologists Neuropsychologists Psychiatrists Therapists

Rehab & allied health

Psychomotor therapists Physiotherapists Osteopaths Speech and language therapists Occupational therapists

Nutrition & dietetics

Dietitians
Resources
Blog Patient handouts Help centre Downloads
Security Pricing Contact us
Sign in Try for free
EN

Region and language
All articles

Child psychiatry session notes: documenting a consultation with the child, parents and school

In child psychiatry, one consultation brings together the child, one or two parents and often the school's view, sometimes with a treatment to monitor. Here is how to keep a clear note on each of these points, with the French legal framework, a template to copy and a completed example.

Delta

Countries covered : France

Why the child psychiatrist's note is different

In child psychiatry you often hear three or four versions of the same week. The child's, each parent's (sometimes far apart) and the teacher's note. And you see the child yourself, playing, fidgeting or staying silent.

On top of that come a doctor's tasks. Prescribing and monitoring a treatment, filling in a certificate for the MDPH (the French local disability office), giving an opinion on school adjustments, writing to the GP. All of this leaves a trace in a file that parents can read.

Are you a psychologist? See our session note for a child or adolescent instead. This article covers the medical consultation in child psychiatry.

Note who said what

"Sleeps badly" means nothing if you do not know who said it, or at which parent's home. Plan one section per source. If a parent did not come but wrote to you, note it in their section with the date and the channel (email, phone call, letter).

  • The child
    • How to note it. Their own words in quotation marks when they matter, otherwise a summary
    • Example. Says that "homework takes less time"
  • Each parent
    • How to note it. Each fact attributed to the parent who reports it
    • Example. According to the mother, falls asleep around 10 pm on school nights
  • The school
    • How to note it. The medium and the date
    • Example. Teacher's note in the home-school notebook of 10 October
  • You
    • How to note it. What you see and measure, without interpretation
    • Example. Stays seated for 20 minutes during the building game

Also note in one line who was present and how the consultation was split (everyone together, child alone, parents alone).

When parents are in conflict, each may describe the other harshly. Note what is reported and attribute it ("according to the father"), without taking it on as your own view. Write nothing that reads like an assessment of a parent you have not met.

Prescribing and monitoring treatment

When you prescribe, the note also becomes the treatment log.

  • The treatment. Drug, formulation, dose, time of intake, start date, last change and its reason.
  • Actual intake. Missed doses, delays, differences between the two homes.
  • The effect. What the child, each parent and the school see, each in their own section.
  • Tolerance and measurements. The adverse effects you look for and the parameters required by the summary of product characteristics (SmPC), with their values and dates.
  • Information given. What was explained to the child, in words suited to their age, and to the parents.

Take methylphenidate, often prescribed for ADHD in France. Since 13 September 2021, the annual initial prescription can be made by a neurologist, a psychiatrist or a paediatrician, in hospital or in private practice. Any doctor can then renew it during the year. Each prescription is limited to 28 days and written on a secure prescription form.

The methylphenidate SmPC asks for blood pressure and pulse to be checked at each dose adjustment, then at least every 6 months, on a percentile chart. Height, weight and appetite are measured at least every 6 months, on a growth chart. New or worsening psychiatric disorders are monitored at each adjustment. It also recommends stopping treatment at least once a year, preferably during the holidays. Check the SmPC of the product you prescribe.

The HAS (Haute Autorité de santé, the French national health authority) offers a weekly follow-up sheet that the child fills in with a parent (effect at school and in the evening, appetite, sleep, adverse effects), with a section for the teacher. And if a dose has to be taken at school, a PAI (projet d'accueil individualisé, an individual care plan at school) is needed.

Rating scales: what to note

Rating scales let you compare one consultation with the next. In its July 2024 recommendations on ADHD in children and adolescents, the HAS states that these tools can be repeated during follow-up.

  • ADHD-RS
    • Who fills it in. Parents, teacher
    • What the HAS says (ADHD, 2024). Covers the 18 ADHD criteria of the DSM-IV, freely available
  • SNAP-IV
    • Who fills it in. Parents, teacher
    • What the HAS says (ADHD, 2024). Collects ADHD criteria and oppositional defiant disorder criteria
  • Conners
    • Who fills it in. Parents, teacher
    • What the HAS says (ADHD, 2024). Scoring not validated in French, but useful for follow-up

For each scale, note the name and version, who filled it in, the date, the total score (and any useful subscores) and the conditions, for example on or off treatment. Do not copy out the questions. Several scales are protected by copyright, and the score is enough to compare. If both parents fill in the scale separately, keep both scores. A gap between them is clinical information in itself.

Coordination with the school and other teams

The child often has other professionals involved (school doctor, speech therapist, psychomotor therapist, CMP or CMPP, the French public and non-profit child mental health centres, social workers). The note should say who does what.

  • PAP (plan d'accompagnement personnalisé, a personalised support plan at school). According to the HAS, it can only be set up with a doctor's agreement, preferably the school doctor's.
  • PPS (projet personnalisé de scolarisation, a personalised schooling plan). Offered when the PAP is not enough. It requires recognition of disability by the MDPH and then replaces the PAP.
  • PAI (projet d'accueil individualisé). Needed if the child takes medication at school.

Note the date of each request and where it stands.

The medical certificate to attach to an MDPH application is Cerfa form 15695*01. It includes a section on the impact of the condition, including on schooling. If nothing has changed since the previous certificate, a simplified certificate exists.

For each call or letter with another professional, note the date, the person, what was shared, the parents' agreement and whether the child was told. Also worth knowing, according to service-public.fr, a child already followed in child psychiatry is not eligible for Mon soutien psy (the French state scheme that reimburses psychologist sessions).

Parental authority and separated parents

Article 372-2 of the « code civil » (French Civil Code) sets a presumption. Towards third parties acting in good faith, each parent is deemed to act with the other's agreement when carrying out alone a usual act of parental authority. For a usual act, the doctor therefore does not need to check the powers of the parent present.

No official list says what counts as usual. The Conseil national de l'Ordre des médecins (French National Medical Council) gives examples. Usual acts include compulsory vaccinations, routine care and continuing treatment for a recurring illness. Acts that are not usual include prolonged hospitalisation, heavy treatment "including in the psychotherapeutic field" and treatment with significant side effects. The Council reminds doctors that the legal representatives' consent is sought whatever their relationship status.

For a first consultation, regular follow-up or starting a psychotropic drug, neither the Civil Code nor the Council gives an explicit answer. The prudent approach is to inform both parents and seek their agreement as soon as care goes beyond a one-off consultation, and to note it. If the parents disagree, either can refer the matter to the juge aux affaires familiales (family court judge).

In the file, note who holds parental authority, any court decision you were shown, who was informed and when, who consented and in what form, and your attempts to reach a parent who does not reply. The Council also advises refusing certificates requested in a family dispute (divorce, custody). If a parent asks you for one, note the request and your answer.

What parents can read, and what an adolescent can keep private

For a minor, the right of access to the medical file is exercised by the holders of parental authority (article L1111-7 of the « Code de la santé publique », the French Public Health Code). If the child asks, this access can go through a doctor. Until July 2026, article R4127-45 excluded the doctor's personal notes from this access. Since 30 July 2026, the text no longer mentions them. So assume that parents can read everything. Our article on patient access to their file explains this change.

Article L1111-5 provides an exception. The doctor may do without parental consent when the minor has expressly asked the doctor to keep their health confidential from their parents, and the care is needed to safeguard their health. The doctor first tries to obtain the minor's agreement to involve the parents. If the minor still refuses, they must be accompanied by an adult of their choice, which the doctor notes in the file. The minor can also object to their parents accessing information about this care.

Outside this framework, parents remain informed, and the minor is entitled to information suited to their maturity. Tell the adolescent at the first consultation what will be shared with their parents, what will not, and what would be shared if they were in danger. Then note it.

If you fear a child is in danger, an « information préoccupante » (a report of concern) is sent to the département's intake unit (CRIP). In case of imminent danger, the report goes directly to the public prosecutor, with a copy to the CRIP. The 119 helpline can advise when in doubt. Note the facts, the child's exact words and every step taken, with its date.

The letter to the GP

The GP often renews the prescription. One page is enough. The reason for the consultation and who asked for it. Your summary and the diagnosis made or the working hypotheses. The treatment, what to monitor and when. Who does what (renewal, school adjustments, other care). The date of the next consultation.

Leave out what the child confided to you that is not useful to the doctor, and tell the family what you are writing. For a complete template, see our psychiatric consultation report.

Child psychiatry consultation note template

Copy and adapt. Keeping the same order from one consultation to the next makes information easy to find.

  1. Consultation. Date, length, type (first consultation, follow-up, review).
  2. Present. Who was there, and how the time was split.
  3. Parental framework. Parental authority, residence, people informed, consents obtained (update when something changes).
  4. What the child says. Summary, and their exact words when they matter.
  5. What each parent reports. One subsection per parent, present or not.
  6. School and other professionals. Source, medium, date.
  7. Clinical observation. Contact, behaviour, play, mood, language, measurements.
  8. Treatment. Drug, dose, actual intake, effect, tolerance, parameters.
  9. Rating scales. Name, informant, date, score, conditions.
  10. Summary. Your reading in a few lines, hypotheses to check.
  11. Decisions. Treatment, tests, referrals, adjustments, who was informed.
  12. Safety. One line every time, even to write "no concern".
  13. Next steps. Next appointment, letters, documents awaited.

Completed example (fictional case)

Consultation. 14 October 2026, 30 minutes, follow-up at the practice.

Present. Noé, 10, in his last year of primary school, and his mother. 15 minutes together, 10 minutes with Noé alone, 5 minutes with the mother alone.

Parental framework. Separated parents, joint parental authority, alternating residence. Written consent from both parents for the treatment in June 2026. The father, absent, emailed his observations on 8 October.

What Noé says. "Homework takes less time." Is "not hungry at lunch" but eats well in the evening.

What the mother reports. Falls asleep around 10 pm on school nights, compared with 9 pm before treatment. Reduced appetite at lunch, made up at snack time and dinner. No missed doses during her week.

What the father reports (email of 8 October). Same observation about appetite. Homework easier. Two missed doses during his week.

School. Teacher's note in the home-school notebook. Noé stays seated longer and interrupts the class less. PAP in place since September.

Clinical observation. Good contact, calmer than in July. Focused on a building game. No tics, no sadness.

Treatment. Prolonged-release methylphenidate, 20 mg at 7.30 am, since July 2026. Weight 31.2 kg (31.5 kg in July), height 140 cm, pulse 92/min, blood pressure 108/66, plotted on the charts.

Rating scales. ADHD-RS parent version, filled in by the mother on 13 October on treatment, score 22 (38 in May, before treatment). Teacher version, filled in on 9 October, score 20 (35 in May).

Summary. Clear benefit in class and with homework, seen by both parents and the teacher. Reduced lunchtime appetite without notable weight loss. Sleep onset delayed by about an hour, to be monitored.

Decisions. Same dose, taken at 7.30 am at the latest, substantial afternoon snack. HAS follow-up sheet offered to both homes. No PAI (no dose at school). Explained to Noé why the dose stays the same. Report sent to both parents.

Safety. No concern.

Next steps. Letter to the GP for renewal. Next consultation in January 2027. Discuss the yearly treatment break over the summer in June.

How Delta works

Delta is an AI assistant for mental health professionals. During the consultation, Delta transcribes what is said, then prepares a report that you review. You can also dictate your observations right after. When several people speak, your review also checks that each statement is attributed to the right person.

The report takes your specialty and your approach into account. It is added to the child's file, which brings out how things change over the consultations, for example sleep, appetite or feedback from school over several months. Delta also drafts your assessment reports, letters and certificates.

Data is hosted in France, with a provider certified for health data (HDS). AI processing, transcription included, runs on servers located in France. The patient's name and identifying information are pseudonymised before going through the AI, no audio file is kept, data is never used to train models, and it is encrypted in transit and at rest. On informing families, see our article on consent to AI note-taking.

Frequently asked questions

Do both parents need to agree to a child psychiatry consultation?

For a usual act, article 372-2 of the Civil Code presumes that the parent present acts with the other's agreement. But no text clearly classes child psychiatry follow-up or a psychotropic drug as a usual act. To be prudent, inform both parents, seek their agreement as soon as follow-up goes beyond a one-off consultation, and note it.

Can parents read their child's child psychiatry file?

Yes, the holders of parental authority exercise the right of access (article L1111-7 of the Public Health Code). The exception covers care the adolescent has asked to keep confidential under article L1111-5.

Can an adolescent see a doctor without their parents knowing?

Yes, under article L1111-5, when the care is needed to safeguard their health. The doctor first tries to persuade them to involve their parents. If they refuse, they must be accompanied by an adult of their choice, and the doctor notes it.

What should I note when parents contradict each other?

Both versions, each attributed to its author, without deciding between them if you cannot check. Your own observation goes in a separate section.

Who can prescribe methylphenidate to a child in France?

A neurologist, a psychiatrist or a paediatrician, in hospital or in private practice, makes the annual initial prescription. Any doctor can then renew it within the year, on a secure prescription form for 28 days at most.

Sources

Cookie policy