PHPM Peer Support Program - Colleague Referral Survey

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.

1.Your First & Last Name(Required.)

2.Your Email(Required.)

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(Required.)

Yes

4.First & last name of colleague being referred(Required.)

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

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)

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

Yes

Unsure

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