French Psychologist Consultation Report Template
Template for a self-employed psychologist's consultation report in France, compliant with the 2012 code of ethics for psychologists, to be kept for 30 years.
How long must a psychological consultation report be kept?
There is no statutory retention period specific to self-employed psychologists, unlike hospital records governed by Article R. 1112-7 of the Code de la santé publique (Public Health Code), which sets 20 years. Professional bodies and the CNIL (France's data protection authority) recommend 30 years from the last consultation to cover the risk of late civil liability claims. At expiry, destruction must be secure, traceable and recorded in the registre de traitements (the GDPR processing register).
Source: Article 226-13 of the Code pénal — Professional secrecy (Légifrance) · updated 2026
About this form
The consultation report (compte-rendu de consultation) produced by a self-employed psychologist in France sits at the intersection of professional ethics and medico-legal obligation. It is governed by the Code de déontologie des psychologues (the national code of professional conduct for psychologists, revised 2012), particularly Article 16, which requires all written professional documents to be proportionate to the referral question and disclosed only to legitimately authorised recipients. Professional secrecy (secret professionnel) is enshrined in Article 226-13 of the French Penal Code (Code pénal), carrying penalties of up to one year's imprisonment and a €15,000 fine for any unlawful disclosure. As a document containing personal health data, the report is also subject to Article 9 of the GDPR (EU Regulation 2016/679 of 27 April 2016), requiring explicit patient consent before any processing or transmission. The recommended retention period is 30 years from the date of the last session, in line with precautionary standards applied to long-term mental health records in France.
Worked example
Sophie Martel, a self-employed clinical psychologist practising in Grenoble (Isère, 38), carries out a neuropsychological assessment for Thomas, aged 9, referred by his paediatrician for suspected attention-deficit/hyperactivity disorder (ADHD). The assessment spans three sessions at €90 each, totalling €270, exempt from VAT under Article 261, 4°, 1° of the Code général des impôts (CGI). She produces a five-page report addressed to the referring child psychiatrist, following signature of the consent form by both parents. Raw scores from the WISC-V and TEA-Ch tests remain in the internal case file and are not included in the transmitted version. The document is sent via the MSSanté secure health messaging platform and archived on a certified HDS server until 2056 (30 years from the final session). Sophie Martel's ADELI number appears in the header as required by Article 16 of the 2012 Code de déontologie.
How to fill out the form
- Identify the parties and the referral context: record in the header the patient's full name, date of birth and — where the document is intended for a third party — an anonymised identifier. Add the psychologist's full identity and ADELI number (the national identifier for all registered health practitioners in France). Specify the nature of the request — self-referral, physician referral, institutional prescription or judicial order — and name the referring party.
- Record session dates, durations and assessment methods: list the date and duration of each interview or evaluation session making up the consultation or assessment, together with every tool or test used, its full bibliographic reference and standardisation date. This traceability is required by Article 16 of the 2012 Code de déontologie to ensure the scientific validity and reproducibility of the conclusions.
- Draft clinical observations and conclusions: present findings in language proportionate to the recipient — clinician, parent or institution — using precise but accessible vocabulary. Do not include raw test scores in any version transmitted to an unqualified third party; detailed scores remain in the internal case file. Conclusions must stay strictly within the scope of the initial referral question, without extrapolation beyond the mandate.
- Obtain and document informed consent: before any transmission, have the patient sign a dated consent form explicitly naming the recipient, the purpose of the disclosure and the information being communicated. If the patient is a minor, both legal representatives must sign. File the signed form alongside the report and retain it for the same recommended period of 30 years.
- Sign, archive and secure: apply the psychologist's handwritten or qualified electronic signature (as defined by EU Regulation eIDAS No. 910/2014), the issue date and the professional stamp. Archive the original in the encrypted patient file — on a certified HDS server if stored digitally — and log the date sent, the secure transmission method used (the MSSanté secure health messaging platform is recommended) and the recipient's identity. Schedule secure, traceable destruction on expiry of the 30-year retention period.
Good to know
- Transmitting a report without the patient's prior written consent — to an employer, insurer or public body — breaches Article 226-13 of the Code pénal, punishable by up to one year's imprisonment and a €15,000 fine. Always obtain and retain the signed consent form before any disclosure.
- Storing psychological reports on a non-certified cloud service (personal email, consumer file-sharing) violates Article L. 1111-8 of the Code de la santé publique and Article 9 of the GDPR. French law requires an HDS-certified host (hébergeur de données de santé). GDPR fines can reach €20 million or 4% of global annual turnover (Article 83(5) GDPR).
- Drawing conclusions beyond the original referral question — such as professional fitness, legal capacity or child-custody recommendations without a judicial mandate — exposes the psychologist to disciplinary sanction under Article 16 of the 2012 Code de déontologie and to civil liability for overstepping the scope of the mission.
Frequently asked questions
How long must a psychological consultation report be kept?
There is no statutory retention period specific to self-employed psychologists, unlike hospital records governed by Article R. 1112-7 of the Code de la santé publique (Public Health Code), which sets 20 years. Professional bodies and the CNIL (France's data protection authority) recommend 30 years from the last consultation to cover the risk of late civil liability claims. At expiry, destruction must be secure, traceable and recorded in the registre de traitements (the GDPR processing register).
Can a patient access or obtain a copy of their report?
Yes. Under Article 15 of the GDPR (right of access) and Article 5 of the 2012 Code de déontologie (which enshrines respect for the person), every patient may request their personal data. The psychologist has one month to respond (Article 12 GDPR), extendable to three months for complex cases where written notice is given. Communication may be direct or, where clinically warranted, mediated through another qualified professional. Restrictions are permissible only in exceptional, documented circumstances.
Is written consent required before transmitting a report to a third party?
Absolutely. Article 16 of the 2012 Code de déontologie requires that any report addressed to a third party — physician, school, employer or insurer — be disclosed only with the patient's explicit and informed written consent, or that of their legal representative if the patient is a minor. Consent must be obtained before drafting, and the signed form must be retained for 30 years. Transmitting without consent triggers liability under Article 226-13 of the Code pénal: up to one year's imprisonment and a €15,000 fine.
What information must a psychological consultation report contain?
Under Article 16 of the 2012 Code de déontologie, the report must be circumstantiated and proportionate to the referral question. Required elements include: the psychologist's full identity and ADELI number (the national identifier for registered health practitioners in France), session dates and durations, the patient's identity or an anonymised reference, the initial referral question and its source, tools and tests used with their standardisation dates, clinical conclusions adapted to the recipient, and a confidentiality notice. Raw test scores remain in the internal case file and are never disclosed to unqualified third parties.
How must digital records be stored securely?
Reports containing health data are subject to Article 9 of the GDPR and Article L. 1111-8 of the Code de la santé publique, which require storage with a certified HDS provider (hébergeur de données de santé — certified health data host). The ANSSI (French national cybersecurity agency) recommends AES-256 encryption, strong authentication, full access audit logs and encrypted off-site backups. Non-compliance exposes the practice to GDPR fines of up to €20 million or 4% of global annual turnover (Article 83(5) GDPR).
Are fees for drafting a report subject to VAT in France?
Generally no. Fees charged by self-employed psychologists for clinical psychology sessions are exempt from VAT under Article 261, 4°, 1° of the Code général des impôts (CGI — France's General Tax Code). Drafting a consultation report is considered inseparable from the therapeutic act and benefits from the same exemption. However, an assessment commissioned exclusively by an employer or insurer with no therapeutic purpose may fall under the standard 20% VAT rate.
Official sources
Updated on 2026-06-27
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