PHPM Peer Support Program - Colleague Referral

Refer a Physician Colleague for Peer Support

To refer a colleague to the Peer Support Program, please fill out the form below. The information you share with us will be kept confidential – only viewable by the Peer Supporter and program administrator for the purpose of facilitating a match.

We will reach out to your colleague as soon as possible, generally within 72 hours, to connect them with a Peer Supporter. Please ensure you have your colleague’s permission prior to filling out the form. If you have any questions, please contact PHPM.PeerSupport@phabc.org.

If your colleague needs immediate support or is in crisis please have them reach out to the Mental Health Support Line at 310-6789, or to the BC Crisis Line at 1-800-784-2433. Both are available 24/7 to help.

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* 1. Your First & Last Name

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* 2. Your Email

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* 3. 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

Yes

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* 4. First & last name of colleague being referred

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* 5. Colleague’s contact information (email and/or phone number)

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* 6. 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

Experience(s) of discrimination or alienation/othering at work (ex: related to race, gender identity, sexual orientation, physical ability or other) from patients, colleagues, or staff)

Prefer not to say

Other (please specify)

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* 7. Would your colleague like to have you included in the peer support session(s)?

Yes

Unsure

PHPM Peer Support Program - Colleague Referral

Refer a Physician Colleague for Peer Support

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* 1. Your First & Last Name

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* 2. Your Email

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* 3. 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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* 4. First & last name of colleague being referred

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* 5. Colleague’s contact information (email and/or phone number)

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* 6. Reason for referral (Check all that apply)

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* 7. Would your colleague like to have you included in the peer support session(s)?

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