Become A Volunteer Volunteer Form Telephone Crisis Counselor Volunteer Application Telephone Crisis Counselor Volunteer Objectives: provide callers in crisis or in need of support with acceptance, compassion and respect in order to lower anxiety and facilitate their innate coping skills; help callers capitalize on their strengths in the prevention of self destructive behaviors or suicide; provide referrals and information about community programs and resources. All information provided is private and confidential. Items marked with an asterisk (*) are required. Date* Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone (including area code)*Cell Phone (including area code)Work Phone (including area code)Email* Enter Email Confirm Email Preferred Method of Contact* Home Phone Cell Phone Work Phone Email Please check one or more methods by which we may contact youAre you currently employed?*YesNoPlease indicate type of employment*Full-TimePart-TimeCurrent Employer*Please enter Employer name, your position, duties and dates of employment. If unemployed at this time, please so state and enter information about your last employerAre you currently a student?*YesNoPlease indicate your status as a student*Full-TimePart-TimePlease indicate your current academic level*UndergraduateGraduatePost-GraduateName of School and Major/ProgramDo you have any special needs regarding the workplace?*YesNoSpecial Needs Description*Please describe any special needs you have which would impact on your work. At this time the premises are not wheelchair accessibleAre you fluent in any languages other than English?*YesNoPlease enter the other language(s) you speak*How did you hear about Response?*Examples: name of newspaper, search engine, web site, person, etc.Please describe in detail your motivation to help others, including any life experiences or other information that might be relevant.*What do you feel is your greatest asset for becoming a telephone counselor?*What do you expect to gain from your volunteer work at Response?*Personal ValuesOur callers come from various cultural, social, ethnic, and religious backgrounds. Their belief system, values, and ideals may be different from yours. Options or alternatives the caller may find acceptable may not be acceptable to you. PLEASE ELABORATE ON EACH QUESTION.1. What are your feelings/thoughts about suicide?*2. How might your religious or spiritual beliefs influence your ability to talk with callers?*3. What are your feelings/thoughts about people who remain in abusive relationships?*4. How would you feel about talking with a gay, lesbian, bi-sexual, transgendered, or questioning caller?*5. What are your feelings/thoughts about people with mental illness?*6. How would you feel about discussing sexual issues or concerns with callers?*7. What are your feelings/thoughts about people who use drugs?*8. What is your opinion of people who are "chronically negative" and don't seem to want to change?*9. How would you handle a caller whose attitude, opinion and beliefs were at odds with yours?*If you are selected as a telephone counselor:Will you be able to make a one year commitment to Response upon completion of Part Two of your training (if invited) by coming to a four hour shift once a week?*YesNoNot SurePlease explain why you cannot or are not sure*Having reliable transportation is a condition of acceptance as a telephone counselor.I have reliable transportationI don't have reliable transportationPlease explain why you do not have reliable transportation*Students: will you be available to volunteer over extended school breaks?*YesNoNot SurePlease explain why you cannot or are not sure*References Please list the names, phone numbers and email addresses of three people we can call for personal/professional references. References will only be contacted if you are accepted into Part II of the training program. References are held in the strictest confidence and will not be shared outside of Response for any reason 1st Reference Name* First Last 1st Reference Phone*1st Reference Email* Enter Email Confirm Email 2nd Reference Name* First Last 2nd Reference Phone*2nd Reference Email* Enter Email Confirm Email 3rd Reference Name* First Last 3rd Reference Phone*3rd Reference Email* Enter Email Confirm Email Date of Birth (Required for Background Checking)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender (Optional)CommentsThis field is for validation purposes and should be left unchanged.