Patient Check List

Read the statements and answer yes or no to all that apply. We will build you a printable checklist you can print out and bring to your healthcare provider. Please know we don't save your information.


I sometimes feel out of touch with reality.

hearing  see  feeling

Others tell me what I am hearing, seeing, or sensing (e.g. people, animals, or objects) are not actually there (hallucinations).

This happens ___ times per month.

stealing  broken-heart

I have beliefs or fears that a loved one (perhaps a spouse, caregiver, or friend) is stealing from me or being unfaithful (delusions).


I have shared these experiences with my loved ones.


These experiences are having an impact on my family or caregiver.