COPLINE

Stephanie Samuels, Creator and Founder

501 Iron Bridge Road #6

Freehold, NJ  07728

(732) 577-8300x8

1-(800) COPLINE

1-(800) 267-5463

Fax: (732) 577-9960

E-Mail: Copline@optonline.net

 

 

REFERRAL QUESTIONAIRE

 

 

 

On a separate piece of paper, please fill out the following questionnaire so you can potentially be added to a National database.

Respectfully,

 

Stephanie Samuels, Founder

 

 

1.        Do you do any evaluations for hiring, firing, fit for duties or promotions and demotions for any department?

 

If so, please state whom.  If it is throughout the State please say “Statewide”.

 

2.     Does anyone in your practice do any evaluations for hiring, firing, fit for duties or promotions and demotions for any department?

 

If so, please state whom.  If it is throughout the State please say “Statewide”.

 

  1. What networks do you belong to?

 

  1. What insurance companies DO NOT acknowledge your license?

 

  1. What division are you licensed by?  i.e. Board of Social Work, Board of Medicine, Board of Psychologists.

 

  1. Is there a specialty that you would like us to keep in our database?  i.e. Bereavement, PTSD, Couples Counseling

 

  1. Is there a specific issue that you are not comfortable being referred to for?  If yes, please state the issue.

 

  1. If you are part of a group, is there a specific person that we should call within your group to refer the caller to that will assess their needs and make the referral within the group?  If yes, please give their name and number with an extension if applicable.

 

  1. What do you expect from the hotline?

 

  1. Would you be interested in volunteering to be a listener on the line, or take a rotation on a back up beeper if needed?

 

 

 

 

  1. What makes you qualified to work with law enforcement officers and their families?

 

 

  1. Have you ever taken a shift with an officer? If yes
    1. What department?
    2. Did you find it valuable?
    3. What did you learn?

 

If No:

a.        Would you be willing to?

b.       Why or why not?

 

      

 

      

PLEASE SEND A COPY OF YOUR RESUME OR CV, CURRENT LICENSE AND INSURANCE POLICY ALONG WITH THIS QUESTIONAIRE.