Distress Centre Wellington/Dufferin is a 24/7 telephone service which provides a listening ear for persons who are in crisis, distress or in need of someone to talk to.  Our phone lines are staffed by trained volunteers.  To maintain our high standards of service, we try to carefully assess suitability for this type of work before accepting any new applicants for training.  The applicant named below has given your name as a personal reference and has applied to become a telephone volunteer at Distress Centre Wellington/Dufferin.

Your reference will remain strictly confidential.  We never select or reject an applicant on the basis of a single positive or negative reference, rather attempt to develop a complete picture of the person from several perspectives.

Thank you for your help in completing this form.  We would prefer a web-based reply.  If, however, you would rather speak to someone about the applicant, please call 519-821-3760 and leave a message to that effect for the Program Co-ordinator.

Please note that this form is CONFIDENTIAL WHEN COMPLETED.

We would appreciate your comments on the following:

Name of Potential Volunteer	*	Name of Referee*
1. How long have you known this person?	*
2. In what capacity and under what circumstances?	*
3. How would you describe this person?	*
4. How does s/he get along with people in general?	*
With people in authority?	*
With people of other cultures?	*
5. What particular strengths does this person show in relating to others?	*
6. What particular weaknesses does this person show in relating to others?	*
7. How open is s/he to other points of view?	*
8. How well does s/he respond to feedback and/or constructive criticism?	*
9. Can you comment on his/her emotional maturity and stability?	*
Ability to cope with stress?	*
Dependability?	*
10. Do you have any other comments which might help us to make a realistic appraisal of his/her suitability?	*
By clicking the submit button below, I am giving Distress Centre Wellington-Dufferin permission to use the information supplied above for the sole purpose of assessing the suitability of the potential volunteer named previously (above) in this form as a volunteer with Distress Centre Wellington-Dufferin.
Please type your name and daytime contact number.	*
Please enter today's date.	*