CONFIDENTIAL VOLUNTEER QUESTIONNAIRE
This questionnaire will assist Copline facilitators in getting to know you and assess your readiness to be a volunteer. The information requested will allow us to provide realistic role playing and prepare you for the role of active listener with Copline. Some of the questions contained in this form center around issues related to volunteering on the hotline and may appear to be personal in nature. We require honest answers to allow for the best assessment and training opportunities.

Please note: ALL APPLICANTS MUST HAVE AT LEAST 10 YEARS OF FULL TIME SERVICE AS A SWORN LAW ENFORCEMENT OFFICER AND HAVE RETIRED IN GOOD STANDINGS TO APPLY.

Thank you,
Stephanie Samuels, Director
Email address *
Date *
MM
/
DD
/
YYYY
Name: *
Address: *
City: *
State/Province:
Telephone: *
Birthday: (Day and Month Only!) *
Do you have 10 years experience as a SWORN FULL TIME OFFICER? *
Most recent agency: *
Did you retire in good standing and would you be able to be rehired? *
If no, please describe the circumstances surrounding your retirement.
Did you retire in lieu of termination or discipline? *
If yes, please describe the circumstances.
How did you find out about Copline? *
What types of calls do you expect to get on the hotline? *
What type of calls do you feel would be the most comfortable for you to handle? (Explain why) *
What type of calls would be least comfortable for you to handle? (Explain why) *
Can you say, with a great deal of certainty, that you can offer emotional support and a non-judgmental atmosphere to all callers, even those who have engaged in behaviors that you find offensive, immoral, or of a nature that discredits the profession of law enforcement? *
What concerns do you have, if any, about being a volunteer? *
Do you have any concerns or questions about Copline itself? *
Why do you want to be a hotline volunteer? *
What do you expect from the support staff on the hotline?
Do you have any critical incidents from your career that stick out in your mind? (Yes / No, Do you still dream about it? How did your department handle them? Please explain) *
Have you been diagnosed with PTSD? *
If you have been diagnosed, how long has it been since you have experienced symptoms or if you are still experiencing symptoms, how do you manage them? *
Have you been diagnosed with Depression? *
If you have been diagnosed, how long has it been since you have experienced symptoms or if you are still experiencing symptoms, how do you manage them? *
Have you been in therapy? *
If you answered yes to the above question, was it a positive experience and why or why not? *
If you answered yes to having been in therapy, would you recommend the therapist that you saw to other officers and would you recommend they be added to a national referral list? If so, please provide full contact details (name, address, telephone, email) for the therapist. *
Have you been or currently are on an antidepressant or anti-anxiety medication? *
If you answered yes, what was your experience with the medication? *
Are any of your family members currently on an antidepressant or anti-anxiety medication? *
If you answered yes, what was their experience with the medication? *
Have you had any issues with opioid addiction, pain killers, alcohol abuse, etc? *
If yes, please explain. *
How many years were you in law enforcement? *
Did you receive an early retirement? Please explain the circumstances and if it was determined to be an accidental disability. *
What departments did you work for and how long at each department? *
What was your rank at retirement? *Retired Law Enforcement ID will be required at the first day of the mandatory training* *
During an officer's career it is common to be exposed to many psychological stressors, especially being brought up on departmental, civil or criminal charges. Were you or someone close to you ever brought up on any of these types of charges and FOUND GUILTY of them? (Please explain to include who was the person, how they were connected to you, what was the outcome, did you suffer any effects from the incident(s), both personally and professionally and how did you handle the stress?) *
Were you or someone close to you ever brought up on these types of charges and CLEARED of them? (Same details as above) *
Has anyone ever told you that you have or had a drinking problem? *
If yes, do you agree? (Please explain)
Who was the person that told you?
How did you feel about the person the person who confronted you?
Did you get help and if so, what type? (Inpatient, AA, private counseling, EAP, etc.)
Have you thought about killing yourself? *
If yes to the above question, what were the circumstances and what made you decide to live?
Has anyone close to you thought of killing themselves? *
If yes to the above question, whom, what were the circumstances and how were they going to commit suicide?
Has anyone close to you ATTEMPTED suicide? *
If yes to the above question, whom, what were the circumstances and how was it attempted?
Has anyone close to you COMPLETED suicide? *
If yes, whom, what were the circumstances, how did they carry it out and how was it handled personally?
Have you had any military experience? *
If yes, what branch, did you see combat and which combat?
Do you do anything in particular to relieve stress? *
If yes, please explain.
Is there anything you would like to tell us about yourself that you feel would benefit us in getting to know you better?
Submit
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Copline Inc.. Report Abuse
Google Forms