Psychological assessment report: template and writing framework

Writing the report is a key moment in a psychologist's work, but it is also a profession with a specific framework: professional confidentiality and no legal obligation to provide a written document to the patient. Knowing what to write, in what format, and for whom is just as important as the structure.

The framework for psychologists' written records

On the reimbursement side: private practice consultations are generally not covered outside the "Mon soutien psy" scheme, the terms of which are evolving, to be checked on ameli.fr.

The structure of a psychological assessment report

The report follows the psychologist's reasoning, from the initial request to the recommendations:

1. The request. The question asked of the psychologist, the context of the referral.
2. Contextual elements. The person's history, clinical history useful for understanding.
3. The tools used. Interviews, tests, briefly presenting any unusual test and the reason for choosing it.
4. Clinical data. Observations and results, by major area of functioning (emotion, behaviour, thought, relationships) or test by test.
5. Interpretation. The psychologist's analysis, integrated into a coherent model.
6. Conclusion. The answer to the initial request.
7. Recommendations. Care pathways, highlighting positive aspects.

The text benefits from being concise: it contains only what is useful to the reader.

The feedback session

Best practice combines verbal and written feedback. Sharing the report with the person concerned takes place during an interview: explaining, making connections, identifying pathways—a key moment that links the assessment work to the person's daily life.

Session notes and follow-up file

For psychotherapeutic follow-up, clearly distinguish your personal notes (internal use) from what you might formalise. Dated, concise notes focused on what is useful for the continuity of care are sufficient in most cases, as the essential element remains the quality of the relationship, not the volume of writing.

Saving time on writing

Assessment reports and follow-up notes take time. Start with a fixed template, standardise your interpretation and recommendation phrasing, and dictate your summary right after the session.

This is exactly what Delta does: live note-taking or post-session dictation, and the tool generates a structured document according to your template, with a longitudinal patient memory from one session to the next. Health Data Hosting (HDS), GDPR compliant: your writings remain confidential and belong to you.

Frequently asked questions