Hallucinations Rating Scale

Applicant Name: _______________________________

James Wilson Date: _______________
August 17, 2023

Instructions: For each item below, rate the applicant's experiences on a scale of 0-5. Include any
additional notes or comments in the designated column. Ensure to respect privacy and maintain
confidentiality.

Item No. Assessment Description Rating Notes & Comments

Area (0-5)

1 Frequency How often do the Reports seeing shadows occasionally,

hallucinations 2 especially when alone.
occur?

2 Duration How long do the Frequent reports of hearing whispers,

hallucinations 3 unclear if related to surroundings.
typically last?

3 Intensity How intense or Rarely feels a sensation of something

vivid are the 1 crawling on skin, not persistent.
hallucinations?

4 Distress How distressing No reports of unusual smells.

Level are the 0
hallucinations?

5 Interference How much do No reports of unusual tastes.

they interfere 0
with daily
activities?

6 Reactivity How often do you No reports of sensations inside the

react to the 0 body.
hallucinations?

7 Location Where do they Occasionally reports simultaneous

seem to originate visual and auditory hallucinations.
2
(e.g., inside
head, external)?

8 Content Type What type are Reports that auditory hallucinations

they mainly (e.g., can last up to several hours.
4
voices, visions,
tactile)?

9 Emotional What emotions Occur a few times a week.

Response do the
hallucinations 3
evoke (e.g., fear,
sadness)?

10 Sleep Do they affect Hallucinations have a moderate effect

3 on social and occupational functioning.
Disturbance sleep?
Auditory hallucinations are clear but vague;
11 Clarity How clear are the 3 visual hallucinations are shadowy but distinct.
hallucinations?
 12 Recognition Are they Recognizes auditory hallucinations as
recognized as unreal, but sometimes believes visual
2
unreal or hallucinations.
believed to be
real?

13 Content Are they Mostly neutral content, rare reports of

Nature commanding, threatening voices.
1
threatening,
neutral, or
comforting?

14 Triggers Are there known Stress and isolation seem to

triggers (e.g., 3 exacerbate hallucinations.
stress, places,
people)?

15 Coping Are there Uses music and talking to friends to

Strategies strategies used 4 cope, but sometimes struggles.
to cope with or
manage them?

16 Medication How do Medications reduce frequency but not

Influence medications 2 completely effective.
influence them (if
applicable)?

17 Sensory Which senses Auditory and visual senses are

Modality are involved 3 involved.
(e.g., auditory,
visual, tactile)?

18 External Are there Dim lighting seems to slightly worsen

Factors external factors visual hallucinations.
1
that
enhance/worsen
them (e.g.,
lighting)?

19 Temporal When do they Occur more frequently at night and

Pattern usually occur 3 when alone.
(e.g., night,
morning,
randomly)?

20 Past Were there past Past interventions provided temporary

Interventions interventions? 3 relief but not sustained.
How effective
were they?

Rating Scale:

0: Not at all / Never 3: Sometimes / Moderate

1: Rarely / Very mild 4: Often / Moderately severe

2: Occasionally / Mild 5: Constantly / Very severe

 Further comments/observations:
The applicant's hallucinations primarily involve the auditory and visual senses and tend to be
exacerbated by stress and isolation. They usually occur at night and when the applicant is alone.
Medications and past interventions have provided some relief, but the hallucinations persist.
Coping strategies, such as listening to music and talking to friends, are sometimes helpful, but the
applicant still struggles. Further assessment and tailored interventions may be necessary.