PTSD assessment report template (with a filled example)

A PTSD assessment report is the document in which a psychologist describes the reported event, the symptoms observed in each criterion cluster, the measures used and their results, the impact on daily life, then gives a clinical conclusion and a treatment recommendation.

When to write this report

It usually follows two or three assessment sessions, when a client seeks help after an event (a road traffic collision, an assault, a disaster, repeated abuse) or when a GP refers someone for an opinion. It then becomes the baseline: the same structure, repeated at three or six months with the same measures, shows change over time. It does not replace your therapy session notes, nor a therapy progress report, which follow on from it.

What the reference texts say

Symptom clusters in DSM-5 and ICD-11

The National Center for PTSD's PCL-5 follows the 20 DSM-5 PTSD symptoms, grouped into four clusters. For the full criteria, refer to DSM-5-TR, the current edition.

• Cluster B, intrusion (PCL-5 items 1 to 5): unwanted memories, nightmares, flashbacks, distress and physical reactions to reminders.
• Cluster C, avoidance (items 6 and 7): of memories, thoughts, places, people or situations linked to the event.
• Cluster D, negative alterations in cognitions and mood (items 8 to 14): partial amnesia, negative beliefs, blame, persistent negative emotions, detachment.
• Cluster E, alterations in arousal and reactivity (items 15 to 20): irritability, risk taking, hypervigilance, startle, concentration, sleep.

The WHO ICD-11 (code 6B40) uses a narrower definition built on three elements: re-experiencing the event in the present (vivid intrusive memories, flashbacks, nightmares), avoidance, and persistent perceptions of heightened current threat (hypervigilance, startle). Symptoms "persist for at least several weeks" and cause significant impairment. Complex PTSD (6B41) requires that all PTSD requirements are met, plus severe and persistent problems in affect regulation, a diminished or worthless sense of self with shame or guilt, and difficulties in sustaining relationships.

We advise stating which classification you use. The two do not overlap fully: a client can meet one and not the other.

The measures, and what they let you write

• LEC-5 (Life Events Checklist): a list of potentially traumatic events. Useful to identify an index event and earlier exposures.
• PCL-5, National Center for PTSD: a 20-item self-report measure covering the 20 DSM-5 symptoms, total score 0 to 80. According to the National Center for PTSD, initial research suggests a cutoff between 31 and 33 indicates probable PTSD, and a 10-point drop indicates response. It is in the public domain. It serves screening, monitoring and provisional diagnosis.
• CAPS-5, National Center for PTSD: a 30-item structured interview, given by the National Center for PTSD as an example of the structured clinical interview that is the gold standard for diagnosis. It needs an index event and covers the dissociative subtype (depersonalisation, derealisation). Online training is available.
• ITQ (International Trauma Questionnaire), Cloitre et al., 2018: a self-report measure built on the ICD-11 criteria for PTSD and complex PTSD. This is the measure to name when you consider complex PTSD.

You calculate and interpret the score. In the report, give the version used (validated language version, "past month" or "past week"), the total, the cluster scores, then your clinical reading.

Treatment recommendation: NICE NG116

The NICE guideline NG116 (2018) is explicit for adults. Offer individual trauma-focused CBT to adults who present more than one month after a traumatic event (1.6.16), typically over 8 to 12 sessions (1.6.17). Offer EMDR when a non-combat-related trauma happened more than three months ago (1.6.19), and consider it between one and three months if the person prefers EMDR (1.6.18). For complex PTSD, build in extra time to develop trust (1.7.3). Assessment should be comprehensive, covering physical, psychological and social needs and a risk assessment (1.2.2).

In France, the HAS published a scoping note on psychotraumatic syndromes in 2020; its 2026 roadmap planned the adult guideline for the first half of 2026, and we could not find it published in early November 2026.

Suicide risk belongs in a separate note. Samaritans (116 123, UK and Ireland) or 3114 in France can be given to the client as a resource.

Full template to copy

Header. Name, title, registration number (HCPC, PSI, or national register), practice details. Date of report. Recipient and purpose. "Confidential".

1. Referral and question. Who is asking (client, GP, other) and why. Question asked. Dates and number of assessment sessions.

2. Context of the event. Type of event, date, duration, exposure (direct, witness, close person). Attributed to the client: "Mr X reports that…". No unnecessary graphic detail.

3. History. Earlier events (LEC-5 if used), previous mental health history and support, current medication as reported, substance use.

4. Symptoms reported and observed.

• Intrusion: [reported] / [observed in session]
• Avoidance: [reported] / [observed]
• Mood and cognitions: [reported] / [observed]
• Arousal, reactivity, sleep: [reported] / [observed]
• Dissociation: [present or not, examples]
• If complex PTSD is considered: affect regulation, self-concept, relationships
• Onset and duration: [date of onset, course]

5. Measures. Name, version, source, date, reference period, total and cluster scores calculated by the psychologist, clinical reading. Limits (fatigue, language, context of the request).

6. Impact. Work, study, family and social life, travel, independence. Concrete facts rather than adjectives.

7. Strengths and protective factors. Support network, activities kept up, coping already in use, motivation for treatment.

8. Clinical conclusion. Your formulation, the classification used, the level of certainty. Example: "The clinical picture is consistent with post-traumatic stress disorder as defined in ICD-11 (6B40)."

9. Recommendation. Proposed treatment and its reference (trauma-focused CBT, EMDR), contact with the GP if the client agrees, date of reassessment with the same measures.

10. Closing statement. "Report written at the request of [X], handed to [client] on [date]." Signature.

Fully completed fictional example

Fictional case, invented for illustration.

Header. Dr Claire Morgan, counselling psychologist, registration no. [to complete]. Report dated 4 November 2026. Recipient: Mr Jamie Gardner (client), at his request. Purpose: PTSD assessment after a road traffic collision. Confidential.

1. Referral. Mr Gardner, 34, a technician, was advised by his GP to seek help for nightmares and being unable to drive since a collision. He wants to understand what is happening and which treatment to start. Three assessment sessions: 14, 21 and 28 October 2026.

2. Context. Mr Gardner reports that on 2 July 2026 his stationary car was hit from behind on a dual carriageway. He says he stayed conscious, was trapped for a few minutes and believed "the car was going to catch fire". By his account he spent two days in hospital with bruising.

3. History. No previous psychological support reported. LEC-5: no other similar event reported. He says he takes no medication and has been drinking more at weekends since the summer.

4. Symptoms.

• Intrusion: nightmares of the collision three to four nights a week (reported). When describing the event, pallor, tight voice, clenched hands (observed).
• Avoidance: no longer drives, takes a 50-minute bus journey instead of 15 minutes by car, avoids talking about it with family (reported).
• Mood and cognitions: blames himself for "not seeing it coming", says he is "not the same", has stopped playing football (reported). Low affect in all three sessions (observed).
• Arousal and reactivity: startles at car horns, broken sleep, irritable with his partner (reported). Marked startle when a door slammed during the second session (observed).
• Dissociation: brief feeling of being "beside himself" on the bus, without loss of contact (reported).
• Onset and duration: since discharge from hospital, about four months.

5. Measures. PCL-5, English version, past month, completed on 21 October 2026. Total score calculated by the psychologist: 47 out of 80 (B 15, C 7, D 14, E 11). This is above the 31 to 33 range that the National Center for PTSD gives as indicating probable PTSD, and consistent with the clinical interview. The PCL-5 is a self-report measure and is not sufficient on its own for diagnosis.

6. Impact. Six weeks off work, full-time return in September with repeated lateness due to travel. Stopped football. Relationship tension described by Mr Gardner.

7. Strengths. Supportive partner, close brother, job retained, self-initiated request for help.

8. Clinical conclusion. The clinical picture is consistent with post-traumatic stress disorder as defined in ICD-11 (6B40): re-experiencing, avoidance and a persistent sense of threat for about four months, with impact on work and family life. No indication of complex PTSD at this stage. The increase in alcohol use should be monitored.

9. Recommendation. Trauma-focused therapy offered: EMDR or trauma-focused CBT, in line with NICE NG116 (1.6.16 and 1.6.19); Mr Gardner prefers EMDR. Letter to the GP with his consent. PCL-5 reassessment after eight sessions.

10. Closing statement. Report handed to Mr Gardner on 4 November 2026 at his request. It is for him to decide who receives it. Signature.

When a solicitor, insurer or court will read the report

After a collision or an assault, a compensation claim or criminal proceedings often follow, and your report can travel far beyond the GP. When a solicitor or insurer writes to you, we advise against sending anything to them directly. Explain to the client what the document will contain, write it to them, hand it over and let them decide what to do with it. If the third party sends a signed consent form, check that it covers this document and this purpose. In the UK and Ireland, clients can also request their records through a subject access request.

In France, the psychologists' code of ethics (2021 version) sets useful markers that apply well elsewhere: conclusions passed to a third party should include the psychological elements behind them only if necessary, with the person's agreement or prior information (article 15); a psychologist only assesses people they have met (article 13), so do not assess the other driver or an assailant you have not met; every document names its recipient and purpose (article 18). In the UK, Ireland, Belgium and Switzerland, check your own professional body's code.

Three writing habits:

• Keep reports and observations apart: "Mr X reports…", "In session, I observed…". Never "the accident caused…" as a fact you established.
• Consistency, not legal causation: you can write that symptoms began after the event according to the client and that the picture is consistent with PTSD. Legal causation and quantifying damages belong to a medico-legal expert, not to a clinical report.
• Only what is needed: a solicitor does not need the client's family history. A short version, focused on the question asked, protects better than the full report.

Common mistakes

• Writing "PTSD" based on a PCL-5 alone, without an interview or a named classification.
• Giving a score without version, date or reference period, which makes it impossible to compare at reassessment.
• Mixing DSM-5-TR and ICD-11 in the same conclusion.
• Leaving out strengths: a list of symptoms alone gives an incomplete picture.
• Using legal vocabulary ("damage", "attributable") that is not the psychologist's to use.

Checklist before handing it over

• Complete header: name, title, registration, date, recipient, purpose.
• Every sentence about the event is attributed to the client.
• All four clusters (or the three ICD-11 elements) are covered, with duration.
• Each measure: name, version, source, date, period, score, clinical reading.
• The recommendation cites its reference and a reassessment date.
• The client has read the report and knows who it is for.

Why Delta fits this report

A trauma assessment spans several sessions and is repeated months later. Delta is the clinical assistant that keeps the memory of each client: it transcribes what is said during the session, or you dictate your observations afterwards, and the record keeps the whole course of care and its progress in one place. It drafts the report in your vocabulary and structure, learned from your existing reports. It does not calculate any score and does not make diagnoses: the PCL-5 and the conclusion remain yours. Data stays in Europe, in France, on infrastructure certified for health data; client names are pseudonymised before the AI and no audio file is kept. See also our clinical document templates and our psychiatrist referral letter template.

Frequently asked questions

Sources

• NICE, NG116 Post-traumatic stress disorder, recommendations (published 5 December 2018).
• WHO, ICD-11, 6B40 and 6B41, 2025-01 version.
• National Center for PTSD, PTSD Checklist for DSM-5 (PCL-5).
• Code de déontologie des psychologues (France), 2021 version.
• HAS, mental health and psychiatry programme, 2026 roadmap (in French).