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CONFIDENTIAL REFERRAL QUESTIONNAIRE
In an effort to offer our officers the best possible care, we request that you complete the following questionnaire to assure you have the qualifications and experience to be considered for our international database of counselors

Thank you for your interest in our organization, we will contact you shortly after receiving yoru information.

Thank you,
Stephanie Samuels, Founder & Director
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Email *
Website Address
CONTACT INFORMATION
Counselor Name: *
Street Address: *
City: *
State/Province: *
Telephone: *
Agency Name (if applicable)
Do you currently, or have you in the past, conducted evaluations for any law enforcement agency to include hiring, termination, demotions, fit for duty or promotions? *
If yes, please explain and indicate if it's "Stat/Province-wide" or localized.
Does anyone in your practice currently, or have in the past, conducted evaluations, for any law enforcement agency to include hiring, termination, demotions, fit for duty or promotions?
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If yes, please explain and indicate if it's "Statewide" or localized.
Do you currently belong to any professional networks? *
If yes, please list all of them.
Are there any insurance companies that DO NOT acknowledge your license? *
If yes, please explain why.
Are you licensed by any specific organization/division? *
If yes, please list (e.g. Board of Social Work, Board of Medicine, Board of Psychologists, etc.).
Do you have a specialty that we may include in our database (e.g. PTSD, Couples, Bereavement, etc.)? *
Does anyone in your practice currently have experience with Domestic Violence, especially in reference to LEOs / First Responders? *
Required
If yes, please list.
Is there a specific issue that you are NOT comfortable being referred? *
If yes, please list.
Are you part of a group? *
If yes, please indicate if there is a specific person that we should contact within your group to refer the caller to that will assess their needs. (Please include name and telephone number with extension if applicable).
Do you expect anything in particular from the hotline? *
Do you do any intake that includes concussion, mTBI, TBI, and/or Repeated Head Trauma? If so, who do you refer to in your area for culturally competent evaluations and care? If yes, please explain. *
Would you be interested in volunteering as a listener on the line or take a rotation as a backup if needed? *
Do you have any special qualifications or experience working with law enforcement and their families? *
If yes, please explain.
Have you ever participated in a ride-along with a law enforcement officer? *
If yes, please indicate which department and what you learned from that experience.
Would you be willing to participate in a ride-along with a law enforcement officer? *
If no, please explain.
Thank you for your time and cooperation.  Please email a copy of your resume or CV, current license and insurance policy to director@copline.org and we will be in touch with you shortly.
501 IRON BRIDGE ROAD, SUITE 6, FREEHOLD, NJ 07728
PHONE: 1-800-COPLINE (800-267-54630) FAX: 732-577-9960
EMAIL: DIRECTOR@COPLINE.ORG
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