Peer Support Colleague Connection Form

If you would like to connect a colleague to the PG Peer Support Program, please complete this form. A Peer Supporter will reach out to your colleague as soon as possible, generally within 1 week.

If you would like to connect yourself to the PG Peer Support Program, please complete the self-connection form by following this link: self-connection form

The information you share with us will be kept confidential – only viewable by the Peer Supporter, Program Lead (Dr. Ingrid Cosio) and Administrators (Holly Wolitski & Melanie Pierce). Program Lead and Administrator view information for the purpose of facilitating match to a Peer Supporter. If you have any questions, please contact us at PhysPeerSuppPG@outlook.com.

Questions marked with an * require an answer to continue.

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* 1. Your first name:

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* 2. Your last name:

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* 3. Your email address:

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* 4. Your phone number:

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* 5. Permission from colleague being referred:

I have permission from my colleague to refer them to the Peer Support Program and they understand that a Peer Supporter will be reaching out to them.

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* 6. First name of colleague being referred:

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* 7. Last name of colleague being referred:

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* 8. Colleague’s email address:

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* 9. Colleague’s phone number:

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* 10. Reason for referral:
(Check all that apply)

Adverse clinical / patient event

Patient or regulatory complaint

Interpersonal conflict with patient or colleague

Work-related change that has impacted you

Burnout / moral injury

Support with work-life balance

Issue related to equity, diversity and inclusion

Prefer not to say

Other (please specify)

Peer Support Colleague Connection Form

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* 1. Your first name:

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* 2. Your last name:

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* 3. Your email address:

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* 4. Your phone number:

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* 5. Permission from colleague being referred:

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* 6. First name of colleague being referred:

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* 7. Last name of colleague being referred:

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* 8. Colleague’s email address:

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* 9. Colleague’s phone number:

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* 10. Reason for referral:(Check all that apply)

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* 11. Do you have any further comments about your referral?

* 10. Reason for referral:
(Check all that apply)