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 form

Your 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.
1.First name:(Required.)
2.Last name:(Required.)
3.Email address:(Required.)
4.Preferred phone number:(Required.)
5.Preferred method of contact:
(Check all that apply)
6.Preferred modality of peer support:
(Check all that apply)
7.Best time of day to contact you:
8.Reason for reaching out:
(Check all that apply)(Required.)
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.)
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.
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 1-800-663-6729

For more information on PHP programs, visit their site: www.physicianhealth.com