Psychological anamnesis: a first session template for adults and children, and how to write it up

What psychological anamnesis covers

In practice, the word means everything you gather about the person at the start of therapy or an assessment. Who they are, why they are coming now, where the difficulty comes from, how they live today.

Anamnesis has three practical uses. It helps you understand the request and decide whether you are the right person to respond to it. It picks up situations that call for a referral or quick action (suicide risk, violence, an unexplored medical problem). And it gives you a starting point for measuring change across sessions.

It does not have to be done in one go. Many practitioners spread it over two or three sessions and add to it as therapy goes on. The code of ethics also points out that the interview is one of the psychologist's main tools (article 21) and that their assessments remain relative, because the person changes (article 22).

Before the questions, explain the framework

The first session starts with information, not questions. The 2021 code of ethics is clear on this. Article 9 asks psychologists to seek people's “consentement libre et éclairé” (free and informed consent) and to inform them “clearly and intelligibly of the objectives, the methods, any cost and the limits” of the intervention. The same article says that, where relevant, they should be told they can consult another practitioner.

In concrete terms, here is what the person needs to know before telling you their story.

• How the first sessions will run and what you are going to ask them.
• Session length, likely frequency and fee (article 25 asks for fees to be presented in advance).
• Professional confidentiality, and its limits.
• What you write down, how you keep it, and their right to access it.
• That they can stop, decline to answer a question, or see someone else.

Confidentiality and its limits, said simply

Psychologists are bound by professional secrecy. Article 7 of the code refers to articles 226-13 and 226-14 of the code pénal (French Criminal Code) and states that secrecy covers everything the psychologist learns in the course of their work. The Ministry of Health confirmed this in a reply published by the Senate on 12 January 2023, including for psychologists in private practice.

Secrecy has limits set by law. Article 226-14 of the code pénal allows, among other things, informing the judicial, medical or administrative authorities of deprivation or abuse suffered by a minor or by a person unable to protect themselves. Article 17 of the code of ethics asks psychologists facing a risk to the person's psychological or physical integrity to assess “with discernment the course of action to take”, while respecting secrecy and reporting obligations. For more detail, see our article on professional confidentiality for practitioners.

The patient does not need article numbers. They need a few clear sentences, like these.

“Before we start, let me explain how I work. The first two or three sessions help me understand what brings you here and your background. I am going to ask you questions, and you can choose not to answer some of them. What you tell me stays between us, I am bound by professional secrecy. There is one exception. If I think that you or someone else, especially a child, is in serious danger, I might have to alert someone. In that case, I would talk to you about it first whenever possible. I take a few notes for my file, which is protected, and you can have access to it. Sessions last 45 minutes and cost [your fee]. Do you have any questions before we begin?”

Adjust the length, fee and wording to your practice. If you use a digital tool during the session, say so at this point too. The rules to follow are set out in our article on consent to AI note-taking.

Adult intake interview template, area by area

This template is a memory aid. You do not have to follow the order or cover everything in the first session. Let the person tell their story, then come back to the areas still empty. The questions are worded the way you would say them out loud.

• Reason and request
  • What you want to find out. What brings the person, why now, who referred them, what they expect from you
  • Example questions. “What brings you here?” “Why come now rather than six months ago?” “What would you like to change?”
• History of the difficulty
  • What you want to find out. How it began, how it has evolved, what triggered it, what makes it worse or better
  • Example questions. “When did it start?” “Did anything happen at that time?” “What makes things easier, or harder?”
• Impact on daily life
  • What you want to find out. The effect on work, sleep, appetite, relationships, leisure
  • Example questions. “How are things at work at the moment?” “How are you sleeping?” “What have you stopped doing that you used to do?”
• Previous care and treatment
  • What you want to find out. Psychologists, psychiatrists or therapists already seen, medication, hospital stays, what helped and what did not
  • Example questions. “Have you seen anyone about this before? What helped?” “Are you taking any treatment at the moment? Who prescribes it?”
• Physical health
  • What you want to find out. Illnesses, pain, the GP, a medical problem that might explain some of the symptoms
  • Example questions. “How is your health in general?” “Do you have a GP? When did you last see them?”
• Substance use
  • What you want to find out. Alcohol, tobacco, cannabis, other substances, gambling, screens, and any recent change
  • Example questions. “Roughly how many drinks a week?” “Has that changed recently?” “Is there anything else you take to keep going?”
• Life history
  • What you want to find out. Childhood, family of origin, schooling, career, significant events
  • Example questions. “How would you describe your childhood?” “Who mattered to you when you were little?” “Are there moments in your life that particularly marked you?”
• Family history
  • What you want to find out. Mental health difficulties or addiction in the family, suicides, bereavements
  • Example questions. “Has anyone in your family been through similar difficulties?” “Have you lost people close to you?”
• Current situation
  • What you want to find out. Housing, relationship, children, work, money, people around them, ongoing procedures
  • Example questions. “Who do you live with?” “Who can you count on at the moment?” “Are there money or housing worries weighing on you?”
• Resources
  • What you want to find out. What is still holding, the person's strengths, what helps them feel better
  • Example questions. “What does you good, even a little?” “How did you get through difficult times in the past?”
• Safety
  • What you want to find out. Suicidal thoughts, past attempts, violence suffered or committed, risk-taking
  • Example questions. “Sometimes people in your situation think about dying. Does that happen to you?” “Is anyone hurting you at the moment?”
• Goals of therapy
  • What you want to find out. What the person wants to achieve, over what timeframe, and how they will know things are better
  • Example questions. “Three months from now, what would tell you it was worth it?” “What do you expect from me?”

Asking about suicide risk

Many practitioners hesitate to ask the question directly, for fear of “putting the idea in their head”. The Haute Autorité de santé (HAS, the French National Authority for Health) gives a clear answer in its September 2021 recommendation on suicidal thoughts in children and adolescents. It states that explicitly asking a child or adolescent “will not induce such thoughts or even a suicide attempt”, and that identifying them relies on direct questioning. If someone worries you, 3114, the French national suicide prevention line, is free and open 24 hours a day, 7 days a week.

Version for children and adolescents

With a child, anamnesis involves several voices. The parents tell the story, the school often provides the reason for consulting, and the child has their own point of view, which you also need to hear.

Organising the first appointment

• With a young child, you will often see the parents first, alone or with the child, then the child alone, with materials suited to their age (drawing, play).
• With an adolescent, always plan time alone with them. Say in front of the parents what will stay between you and what may be passed on to them.
• Explain to the child, in their own words, why they are there. Many children arrive without knowing who you are.

Article 11 of the code of ethics says the psychologist “ensures as far as possible” that the minor consents and seeks the authorisation of the legal representatives “in accordance with the rules on parental authority”. When parents are separated, the law distinguishes acts that either parent can do alone (everyday acts) from those that need both parents' agreement. Service-public.fr (the French government's official information site) lists routine care in the first category and heavy medical treatment in the second, for example. Its list does not mention psychological therapy. To be safe, inform both parents from the start and ask whether the other parent knows about the appointment.

Template for children and adolescents

• Reason
  • Questions for the parents. “Whose idea was it to come? The school, the doctor, you?” “What worries you most?”
  • Questions for the child or adolescent. “Do you know why you are coming to see me?” “What do you think about it?”
• Pregnancy and birth
  • Questions for the parents. “How did the pregnancy go? And the birth?” “Were there any problems in the first weeks?”
  • Questions for the child or adolescent. (not applicable)
• Development
  • Questions for the parents. “At what age did he walk? Say his first words? Become toilet trained?” “How does he sleep? How does he eat?”
  • Questions for the child or adolescent. “Do you sleep well? Do you have nightmares?”
• Health
  • Questions for the parents. “Have his sight and hearing been checked?” “Does he have any illnesses, any treatment?”
  • Questions for the child or adolescent. “Are there times when something hurts?”
• Schooling
  • Questions for the parents. “Which year is he in? How is learning going? And with other children?” “Is any support already in place?”
  • Questions for the child or adolescent. “What do you like at school? What is hard?” “Do you have friends? Are there pupils who bother you?”
• Family
  • Questions for the parents. “Who lives at home?” “Has there been a separation, a move, a death, a birth?” “How do the custody arrangements work?”
  • Questions for the child or adolescent. “Can you draw me your family?” “Who do you like being with at home?”
• Emotions and behaviour
  • Questions for the parents. “How does he react when he is upset?” “What has changed in the last few months?”
  • Questions for the child or adolescent. “What makes you sad, or angry?” “What do you do when things are not OK?”
• Screens and leisure
  • Questions for the parents. “How much time on screens, and when?” “What activities outside school?”
  • Questions for the child or adolescent. “What do you do when you have free time?”
• Specific to adolescents
  • Questions for the parents. “Have you noticed changes in friends, hours, going out?”
  • Questions for the child or adolescent. “Have you ever tried alcohol, cannabis?” “Is anything happening on social media that weighs on you?” “Do you sometimes think about hurting yourself?”
• Resources and expectations
  • Questions for the parents. “What works well with him?” “What do you expect from these appointments?”
  • Questions for the child or adolescent. “What would you like to change?”

Questions about substance use, relationships and suicidal thoughts are asked to the adolescent alone, once the confidentiality framework has been set.

Version for neuropsychologists

Before an assessment, anamnesis mainly serves to clarify the cognitive complaint and spot anything that could skew the interpretation of tests. The code of ethics requires tests to be scientifically validated (article 21) and assessments to remain cautious (article 22). Anamnesis gives you what you need to do so.

• Cognitive complaint
  • Why it helps. Knowing which functions to explore (memory, attention, language, finding one's way in space)
  • Example questions. “Can you give me a recent example when it got in your way?”
• Onset and course
  • Why it helps. Telling a sudden onset from a gradual one
  • Example questions. “Did it happen all at once or little by little? Is it getting worse?”
• A relative's view
  • Why it helps. The person does not always notice their own difficulties
  • Example questions. To the relative. “What have you noticed that is different? Since when?”
• Education, job, languages
  • Why it helps. Choosing the right norms and interpreting results
  • Example questions. “What level did you reach in your studies?” “What is your mother tongue?”
• Handedness, sight, hearing
  • Why it helps. Adapting how tests are given
  • Example questions. “Which hand do you write with? Do you wear glasses, a hearing aid?”
• Neurological history
  • Why it helps. Stroke, head injury, epilepsy, surgery
  • Example questions. “Have you ever had a blow to the head with loss of consciousness?”
• Treatment and sleep
  • Why it helps. Some medication, fatigue and lack of sleep can affect results
  • Example questions. “What medication do you take? Did you sleep well last night?”
• Mood
  • Why it helps. Low mood or strong anxiety can affect concentration
  • Example questions. “How have you been feeling in recent weeks, in terms of mood?”
• Previous tests
  • Why it helps. Comparing with an assessment or brain scan already done
  • Example questions. “Have you ever had an assessment or a brain scan? Could you bring it to me?”

These elements then go into the anamnesis section of the report. See our psychological assessment report template.

Running the interview without making it an interrogation

A template used badly gives you a session that feels like filling in a form. The person gives short answers, does not dare bring up what really brings them, and you leave with a lot of information and little understanding. A few pointers help avoid this.

• Start broad. One open question at the beginning (“Tell me what brings you here”) and let them talk for several minutes before narrowing down.
• Follow the person's thread. If they mention their father while talking about work, explore it then. You will tick off the “family” area along the way.
• Keep the template in mind, not in front of you. Glance at it at the end of the session to spot the areas still empty, and pick them up next time.
• Ask sensitive questions simply. A direct, calm question about suicide, violence or alcohol often puts people more at ease than a roundabout one.
• Signal changes of topic. “I am going to ask you a few questions about your health, it is something I ask everyone.”
• Sum up at the end. Summarise in two or three sentences what you have understood, and ask if it is right. The person often corrects an important point.
• Finish with what comes next. What you propose, the date of the next appointment, and who to contact in a crisis before then.

If you work remotely, the code of ethics asks you to favour face-to-face meetings and, at a distance, to remain identifiable and secure the exchanges (article 24). For a first session, also check that the person is alone in the room.

Adapting anamnesis to your approach

The template covers the same areas whatever your orientation. What changes is when you fill it in, how structured it is and what you emphasise.

• Cognitive behavioural therapy (CBT)
  • How the anamnesis unfolds. Fairly structured, often supplemented by questionnaires completed by the patient
  • What you focus on. Specific, recent situations. What the person thinks, feels and does at that moment. What keeps the problem going. A baseline measure to track change.
• Psychodynamic or analytic approach
  • How the anamnesis unfolds. Few directed questions, the person speaks freely. The history is pieced together over the sessions.
  • What you focus on. What repeats in the person's history and relationships. The links the person makes themselves. What they leave unsaid or avoid.
• Systemic and family approach
  • How the anamnesis unfolds. Often with several family members. A diagram of the family over three generations (the genogram) is common.
  • What you focus on. Who is asking for what, and for whom. The place of the difficulty in the family. Recent changes (separation, birth, bereavement, move).
• Humanistic approach
  • How the anamnesis unfolds. Loosely structured, centred on what the person is experiencing
  • What you focus on. Present experience, needs, values, what gives meaning.

Even in a non-directive practice, some areas are not left to chance. Safety, current treatment and the GP are checked early, whatever the approach.

What you write down, and what you avoid writing

Article 23 of the code of ethics asks psychologists to collect, file and archive their notes “in a way that preserves people's privacy by guaranteeing respect for professional secrecy”. The GDPR adds two practical constraints. Data must be limited to what is necessary (article 5), and the person can ask to access their data (article 15). Health data is one of the special categories protected by article 9.

One simple rule follows. Write as if the person might one day read your file. For more on the right of access, see our article on patient access to their file.

What to note

• The reason for consulting, with a few of the person's own words in quotation marks
• Reported facts, presented as reported (“she says that...”)
• Past history, current treatment and previous care
• The risk assessment, and what you did as a result
• Your hypotheses, presented as hypotheses
• What was agreed (framework, frequency, fee, information given, the person's agreement)
• Useful contacts (GP, prescriber), with the person's agreement to contact them

What to avoid

• Intimate details of no use to the follow-up
• Judgements and moral adjectives (“manipulative”, “immature”)
• Information about identifiable third parties beyond what is needed (the ex-partner's full name, their employer)
• A diagnosis stated as a certainty from the first session
• Your raw personal reactions, which belong in supervision
• Abbreviations only you understand
• Information unrelated to the request, gathered “just in case”

Example of a written anamnesis summary

Here is what a summary might look like after two sessions, for a fictional patient.

Ms L., 34. Anamnesis summary (sessions of 2 and 9 October).

Reason. Comes on her GP's advice for fatigue and frequent crying for four months. “I can't keep pretending at work any more.”

History. Began after her department was reorganised in June. Broken sleep, waking around 4 am. Says she has stopped exercising and sees her friends less.

Past history. Six months of therapy at 25 after a bereavement, which she found helpful. No current treatment. GP informed of the referral.

Situation and resources. Lives with her partner, no children. Partner supportive, according to her. A close sister.

Safety. Passive thoughts of death (“disappearing for a while”), with no plan or attempt. 3114 number given. To be reassessed at every session.

Substance use. Two to three glasses of wine in the evening since the summer, increasing.

Working hypotheses. Work-related burnout episode, to be clarified. Alcohol use to be monitored.

Agreed framework. Weekly 45-minute sessions, fee presented and accepted. Information on confidentiality and its limits given in the first session.

The structure of your following session notes is covered in our session notes template. And to find out how long to keep this file, see our article on how long to keep patient records.

The ethical framework at a glance (France)

The code de déontologie des psychologues was revised in 2021 (consolidated version of 9 September 2021) and signed by psychologists' organisations. It does not have the force of law, but it is the profession's reference text. Here are the articles that relate directly to anamnesis.

• Principle 1
  • What it says. Respect for the person and their right to information. Everyone must know they can consult the psychologist of their choice directly.
  • What it means for anamnesis. The person chooses what they say and to whom.
• Principle 2
  • What it says. Discretion, secrecy, confidentiality. The psychologist informs people and seeks their informed consent.
  • What it means for anamnesis. The framework is explained before you begin.
• Article 7
  • What it says. Professional secrecy within the limits of articles 226-13 and 226-14 of the code pénal, covering everything learned in the course of practice.
  • What it means for anamnesis. Tell the patient that secrecy exists, and that it has limits.
• Article 8
  • What it says. Between professionals, share only strictly necessary information.
  • What it means for anamnesis. A letter to the GP does not repeat the whole anamnesis.
• Article 9
  • What it says. Free and informed consent. Clear information on objectives, methods, any cost and limits. Option of consulting another practitioner.
  • What it means for anamnesis. The first minutes of the first session.
• Article 11
  • What it says. With a minor, ensure their consent as far as possible and seek the authorisation of the legal representatives.
  • What it means for anamnesis. Explain to the child why they are there, and involve the parents.
• Article 12
  • What it says. With a minor, a protected adult or a vulnerable person, take their situation and the legal rules into account.
  • What it means for anamnesis. Adapt the information and how consent is obtained.
• Article 17
  • What it says. Faced with a risk to the person's integrity, assess the course of action, respecting secrecy and reporting obligations. Option of seeking advice from experienced colleagues.
  • What it means for anamnesis. Ask the safety questions, and know what to do with the answer.
• Article 18
  • What it says. Documents are dated and bear the psychologist's identity, title and signature.
  • What it means for anamnesis. Any summary you send out must be dated and signed.
• Article 23
  • What it says. Notes and data filed and archived in a way that preserves privacy and secrecy.
  • What it means for anamnesis. Where and how you keep your file.

How Delta works

First sessions involve a lot of note-taking. Delta is an AI assistant designed for mental health professionals. During the session, Delta transcribes what is said, then prepares a report that you review and correct. If you prefer, you can also dictate your observations just after the session. The report takes your speciality and approach into account, and is added to the patient's file. You then find the anamnesis, and the whole follow-up and how it evolves, in one place.

Data is hosted in France on infrastructure certified for health data (HDS), and AI processing takes place on servers located in France. The patient's name and any information that could identify them 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. Delta also drafts your assessment reports, letters and certificates.

Frequently asked questions

Sources

• Code de déontologie des psychologues 2021, online text
• Code de déontologie des psychologues, consolidated version of 9 September 2021 (PDF)
• French Senate, written question on psychologists' professional secrecy and reply from the Ministry of Health (12 January 2023)
• Code pénal, article 226-13 (Légifrance)
• Code pénal, article 226-14 (Légifrance)
• Service-public.fr, exercice de l'autorité parentale (exercise of parental authority)
• Haute Autorité de santé, Idées suicidaires chez l'enfant et l'adolescent, repérer, évaluer et orienter (September 2021)
• 3114, French national suicide prevention line
• CNIL (French data protection authority), GDPR chapter II (articles 5 and 9)
• CNIL, GDPR chapter III (article 15)
• CNIL, Répondre à une demande de droit d'accès (responding to a right of access request)
• Commission des psychologues (Belgium), Royal Decree setting the ethical rules for psychologists
• Commission des psychologues (Belgium), Le secret professionnel
• Centre de prévention du suicide (Belgium), 0800 32 123 helpline
• Fédération suisse des psychologues, code of ethics (version of 1 August 2024)
• Swiss Criminal Code, article 321
• Pouvoir judiciaire de Genève (Geneva judiciary), information sheet on capacité de discernement (article 16 of the Code civil)
• La Main Tendue, 143