Pre-bariatric surgery psychological assessment report template

A pre-bariatric surgery psychological assessment report is the written summary a psychologist sends to the multidisciplinary team about a patient being considered for a sleeve gastrectomy, a gastric bypass or another obesity operation. It sets out what was assessed and gives a reasoned opinion. In France, the HAS (the national health authority) guideline validated on 8 February 2024 asks for a written report in the patient's file and for feedback to the patient.

This page complements our psychological assessment feedback template, which does not cover the bariatric pathway.

The official framework: the 2024 HAS guideline

The reference in France is the HAS guideline on second and third level care of adult obesity, part II, before and after bariatric surgery, validated by the HAS board on 8 February 2024. It takes over from the 2009 guideline. Below are the recommendations (numbered R) that shape your report. Quotes are translated from French.

Who assesses, and how much weight the opinion carries

• R53: the preoperative psychological and/or psychiatric assessment must concern all candidates.
• R54: it takes the form of a clinical interview, completed by validated tests if the professional judges it necessary, carried out by a psychologist or psychiatrist experienced in bariatric surgery.
• R24: of experienced psychiatrists and clinical psychologists, "Their opinion is mandatory and essential for the care of these patients."
• R2: bariatric surgery is indicated by a collective decision after multidisciplinary discussion, after at least 6 months of multidisciplinary preparation.

What the report must contain and who receives it

• R58: the assessment is fed back to the patient, to the team and to the GP, as each centre organises it. "A written report, summarising the points assessed, must be placed in the patient's file." The information gathered determines whether the file goes to the team meeting.
• R61: when follow-up is needed, surgery goes ahead only once the patient's psychological state is stable, and the follow-up is reported in writing.

Contraindications, as the HAS words them

R22 lists "severe unstabilised psychiatric disorders", "severe unstabilised major depressive episodes, especially with a history of suicide attempt(s)", "the patient's foreseeable difficulty in taking part in long-term medical follow-up" and "current alcohol or legal and illegal psychoactive substance use disorder". R25 makes impulsive and/or compulsive eating disorders a temporary contraindication. With a history of addictive behaviour, an addiction specialist should be involved (R23). With a history of anorexia or bulimia, the indication must be validated in a referral team meeting at a level 3 centre (R27).

Note the words "unstabilised", "current" and "temporary". Most of these situations call for time, treatment or another opinion, and your report should say so.

After surgery

The HAS points to risks of depression, suicidal ideas and addictions after surgery (R105) and recommends psychological or psychiatric follow-up after past eating disorders, psychiatric or addictive conditions, or weight loss failure (R107 to R109). We recommend proposing this follow-up in the preoperative report.

Suicidal thoughts disclosed during the assessment call for immediate referral. In France, the national suicide prevention line 3114 answers 24 hours a day.

What the psychologist assesses

R55 gives the list. Here it is in the order that suits the interview best.

• Weight history, personal and family, and previous weight loss attempts.
• Relationship with food and eating disorders, current and past, explored with specific questions (R26): binge eating, grazing, compensatory behaviours, emotional eating.
• Current and past psychiatric disorders, care and treatment as the patient reports them.
• Psychoactive substances: personal and family history of use disorders, alcohol use assessed carefully (R57), tobacco.
• Trauma since childhood and current psychosocial stressors.
• Body image.
• Motivation, expectations and understanding of surgery: what the patient knows about life afterwards (eating, lifelong follow-up, deficiencies, relationships) and what they hope for.
• Support and ability to attend long-term follow-up, which links directly to R22.

R56 adds information to give the patient: the higher risk of alcohol use disorder after surgery. Note in the report that you gave it.

What to write and what to keep

The whole team, the GP and often the patient will read the report. In France, the 2021 code of ethics for psychologists frames this document (translated).

• Article 7: the psychologist is bound by professional secrecy within the conditions and limits of the criminal code (Articles 226-13 and 226-14).
• Article 8: the psychologist shares only information strictly necessary for the professional purpose.
• Article 15: when conclusions are passed to a third party, they include the psychological elements behind them only if necessary, and the person's agreement or prior information is required.
• Article 18: documents are dated and carry the psychologist's identity, title, registration number, professional contact details and signature, as well as the recipient and the purpose of the document.
• Article 22: the psychologist gives contextualised, non-reductive conclusions about the psychological and psychosocial resources of individuals.

Here is the split we recommend.

• In the report you send: the R55 points, stated factually; whether anything falls under R22 or R25; points to watch; your reasoned opinion; proposals; the feedback to the patient.
• In your own notes only: detailed accounts of trauma, working hypotheses, intimate content, raw questionnaire results.
• To tell the patient at the first interview: what the assessment is for, who will read the report, that they will get feedback, and that the decision is collective (Article 9 asks psychologists to explain, among other things, the aims, methods and limits of their work).

A reasoned opinion, not a verdict

Many centres expect a "favourable" or "unfavourable" box. Tick it if needed, but the sentence that follows matters more. Some wording that fits Article 22:

• "No psychological factor against surgery at the date of this assessment. Postoperative psychological follow-up proposed given the past depressive episode."
• "Mrs X's expectations remain partly beyond what surgery can offer. We propose two further interviews before the team meeting."
• "The information gathered suggests current binge eating. In line with R25, prior treatment is proposed, with reassessment."

Complete template to copy

Replace the brackets. Remove sections that do not apply rather than writing "nothing to report" everywhere.

Header

[Name], psychologist. Registration number: [number]. [Professional address, phone, secure email].

To: multidisciplinary team at [centre], team meeting on [date]; copy to Dr [GP]. Subject: psychological assessment report before bariatric surgery ([sleeve / bypass / other] being considered).

Patient: [name, date of birth]. Referred by: [Dr, department], on [date].

1. Assessment setting

[Number] interviews, on [dates], [in person / by video]. [Questionnaires used, if any, without raw scores]. The patient was told the purpose of the assessment, who will receive this report and that the decision is collective. They agreed to this report being shared.

2. Weight history

[Onset of weight gain, context, course, previous attempts and what the patient says about them, family weight history].

3. Relationship with food

[Meal pattern, grazing, emotional eating, binge eating, compensatory behaviours, past eating disorders. State whether anything suggests a current eating disorder in the sense of R25].

4. History and current mental state

[Reported psychiatric history, current care and treatment, current stability, sleep, mood. Stay factual, no diagnosis the decision does not need].

5. Substance use

[Alcohol, tobacco, other substances, personal and family history]. Information given on the higher risk of alcohol use disorder after surgery: [yes, date].

6. Life context and significant events

[Family, work, social situation. Difficult life events only if they inform the decision, without detail].

7. Body image

[Relationship with the body, expectations about body changes after weight loss].

8. Understanding, motivation and expectations

[What the patient knows about the operation and lifelong follow-up, expectations, how realistic they are, own motivation or pressure from others].

9. Support and ability to attend follow-up

[Support people, practical constraints, attendance at pathway appointments].

10. Reasoned opinion

• Supporting factors: [resources, understanding, stability].
• Points to watch: [factors to monitor].
• Factors under HAS contraindications: [none / which, temporary or not].
• Opinion: [contextualised wording].
• Proposals: [follow-up before surgery, psychiatric or addiction opinion, reassessment date, follow-up after surgery].

11. Feedback

Feedback given to the patient on [date]. [What they said, agreement or disagreement].

This report reflects the situation at the date of assessment. [Place], [date]. [Signature].

Fully completed fictional example

People and places are invented. No scores are given.

Header

Claire D., psychologist. Registration number: [number]. Practice at 12 rue des Lilas, 69000 Lyon (fictional address).

To: multidisciplinary team at the specialised obesity centre (fictional), team meeting on 14 January; copy to Dr Paul M., GP. Subject: psychological assessment before a planned sleeve gastrectomy. Patient: Nadia B., 41. Referred by Dr Sophie L., surgeon.

Setting

Three interviews in October and November, in person. Mrs B. was told the purpose of the assessment, who will receive this report and that the decision is made at the team meeting. She agreed.

Weight history

Gradual weight gain since the birth of her second child twelve years ago. Four diets, each with weight loss then regain. Mother and sister living with obesity.

Relationship with food

Three meals a day. Grazing late in the day, which she links to tiredness and family tension. No binge eating described, no compensatory behaviour, no history of anorexia or bulimia.

History and current state

Depressive episode in 2019, treated by her GP for a year, no hospital stay. No current treatment. Mood stable since, sleep adequate.

Substances

Occasional alcohol at family meals. Former smoker, stopped three years ago. Information given on 4 November about the higher risk of alcohol use disorder after surgery.

Context, body image

Married, two children, care assistant. Avoids photos and swimming pools.

Understanding and expectations

Good knowledge of the sleeve and of lifelong follow-up. At the first interview, Mrs B. hoped she would "no longer have to be careful"; by the third, she talks about a lasting change in habits and the need for follow-up.

Support and follow-up

Husband attended one dietetic appointment. All pathway appointments kept so far.

Reasoned opinion

• Supporting factors: clear understanding of the operation, change in expectations, support from her husband, regular attendance.
• Points to watch: emotional eating late in the day; past depressive episode.
• Factors under HAS contraindications: none at the date of assessment.
• Opinion: no psychological factor against surgery at this date.
• Proposals: continue interviews until surgery on managing tension and grazing; psychological follow-up after surgery given the past depressive episode.

Feedback

Feedback given on 18 November. Mrs B. agrees with the proposals and wishes to continue follow-up. This report reflects the situation at that date. Lyon, 18 November. Claire D.

Common mistakes

• A bare verdict. "Fit" or "unfit" without reasons does not help the team and goes against Article 22.
• Saying too much. Details of abuse or family conflict do not belong in a document the whole team reads. State that the factor exists and what it implies.
• Concluding too early. When a point is unclear, we recommend offering another interview rather than a fragile opinion.
• Not noting the alcohol information. R56 makes it part of preoperative information.

Checklist before sending

• The patient knows who will read the report and has agreed.
• Each R55 point is covered or noted as not relevant.
• The presence or absence of R22 and R25 factors is explicit.
• The opinion is reasoned and comes with concrete proposals.
• No unnecessary intimate detail, no raw scores.
• The feedback date (R58) and the patient's view are stated.
• Article 18 details are present: date, identity, title, registration number, contact details, recipient, subject, signature.

In Belgium and Switzerland

The HAS guideline applies in France. Elsewhere, follow your centre's protocol (the Liège university hospital, for example, described in 2020 an assessment based on the BIPASS grid). The template still works.

Why Delta fits this report

Delta is a clinical assistant for psychologists. You dictate your observations after the interview, or Delta transcribes what is said in the session, then it drafts the report in your own vocabulary and structure, learned from your existing assessments. It keeps the memory of each patient, so the three interviews, the change in expectations and the R61 follow-up report sit in one place. Data is hosted in France on HDS-certified infrastructure, the patient's name is pseudonymised before the AI, and no audio file is kept. See Delta for psychologists, what Delta is and how to choose psychological assessment report software. The Pro plan costs 35 euros a month including VAT with no commitment, with a 14-day trial and no card required.

Read also: all our clinical document templates.

Sources

• HAS, adult obesity second and third level care, part II before and after bariatric surgery, recommendations (in French), validated 8 February 2024 (decision 2024.0030/DC/SBP).
• HAS, part II practice sheet (PDF, February 2024, in French).
• Full text of the 2024 HAS recommendations, part II (copy of the HAS PDF published by the Rouen university hospital obesity centre, in French).
• French code of ethics for psychologists, 2021 version, Articles 7, 8, 9, 15, 18 and 22.
• Assurance Maladie, Mon soutien psy: eligible patients (in French), read on 5 November 2026.