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 Administrator (Holly Wolitski). 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.

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* 1. First name:

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* 2. Last name:

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* 3. Email address:

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* 4. Preferred phone number:

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* 5. Preferred method of contact:
(Check all that apply)

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* 6. Preferred modality of peer support:
(Check all that apply)

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* 7. Best time of day to contact you:

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* 8. Reason for reaching out:
(Check all that apply)

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* 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.)

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* 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.

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* 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

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