Peer Support Colleague Connection Form Survey

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. Collin Phillips) 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.

1.Your first name:(Required.)

2.Your last name:(Required.)

3.Your email address:(Required.)

4.Your phone number:

5.Permission from colleague being referred:(Required.)

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.

6.First name of colleague being referred:(Required.)

7.Last name of colleague being referred:(Required.)

8.Colleague’s email address:(Required.)

9.Colleague’s phone number:

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

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)

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