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.

Thank you,
Stephanie Samuels, Director

Email address *
Date: *
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Name: *
Your answer
Address: *
Your answer
City: *
Your answer
State:
Your answer
Telephone: *
Your answer
Email: *
Your answer
Most recent agency: *
Your answer
What types of calls do you expect to get on the hotline? *
Your answer
What type of calls do you feel would be the most comfortable for you to handle? (Explain why) *
Your answer
What type of calls would be least comfortable for you to handle? (Explain why) *
Your answer
What concerns do you have, if any, about being a volunteer? *
Your answer
Do you have any concerns or questions about Copline itself? *
Your answer
Why do you want to be a hotline volunteer? *
Your answer
What do you expect from the support staff on the hotline?
Your answer
Do you have any critical incidents from your career that sticks out in your mind? (Yes / No, do you still dream about it, how did you department handle them? Please explain) *
Your answer
Have you been diagnosed with PTSD or Depression? *
Have you or any of your family members been in therapy? *
If you answered yes to the above question, was it a positive experience and why? *
Your answer
Have you or any family member been or currently are on an antidepressant or anti-anxiety medication? *
Have you had any issues with opioid addiction, pain killers, alochol abuse, etc? *
If yes, please explain.
Your answer
How many years were you in law enforcement? *
Your answer
Did you receive an early retirement? Please explain the circumstances and if it was determined to be an accidental disability. *
Your answer
What departments did you work for and how long at each department? *
Your answer
What was your rank at retirement? *
Your answer
During an officers 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?) *
Your answer
Were you or someone close to you ever brought up on these types of charges and CLEARED of them? (Same details as above) *
Your answer
Has anyone ever told you that you have or had a drinking problem? *
If yes, do you agree? (Please explain)
Your answer
Who was the person that told you?
Your answer
How did you feel about the person the person who confronted you?
Your answer
Did you get help and if so, what type? (Inpatient, AA, private counseling, EAP, etc.)
Your answer
Have you thought about killing yourself? *
If yes to the above questions, what were the circumstances and what made you decide to live?
Your answer
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?
Your answer
Has anyone close to you ATTEMPTED suicide? *
If yes to the above question, whom, what were the circumstances and how was it attempted?
Your answer
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?
Your answer
Have you had any military experience? *
If yes, what branch, did you see combat and which combat?
Your answer
Do you do anything in particular to relieve stress? *
If yes, please explain.
Your answer
Is there anything you would like to tell us about yourself that you feel would benefit us in getting to know you better?
Your answer
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