Peer Support Self-Connection Form To speak with a Peer Supporter, please fill out the self-connection form below. Your Peer Supporter will reach out to you as soon as possible, generally within 1 week.If you would like to access the form to connect a colleague to the PG Peer Support Program, please follow this link: colleague connection formYour information 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 a match to Peer Supporter. If you have any questions, please contact us at PhysPeerSuppPG@outlook.com.Questions marked with an * require an answer to continue. Question Title * 1. First name: Question Title * 2. Last name: Question Title * 3. Email address: Question Title * 4. Preferred phone number: Question Title * 5. Preferred method of contact:(Check all that apply) Email Phone call Text Question Title * 6. Preferred modality of peer support:(Check all that apply) Phone call Video call In person Email Question Title * 7. Best time of day to contact you: Morning Afternoon Evenings Question Title * 8. Reason for reaching out:(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) Question Title * 9. Are there any accommodations regarding the peer support match that you would like us to consider? (e.g., stage of career, life stage, gender, speciality, etc.) Question Title * 10. We now have inter-site matching available! If you would prefer to be connected with an out of town Physician Peer Supporter, please let us know. Note: If so, your contact details will be shared with the other site's Lead Physician and Administrator as well, for the purpose of facilitating a match. Question Title * 11. You can also reach out directly to the provincial Physician Health Program for support if you prefer: Physician Health Program (PHP) 24-Hour Help Line 1-800-663-6729For more information on PHP programs, visit their site: www.physicianhealth.com Done