Peer Support for a Colleague

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. The Peer Supporter will reach out to your colleague as soon as possible, generally within 3-4 business days. Please ensure you have your colleague’s permission prior to filling out the form. If you have any questions, please contact

Please enable JavaScript in your browser to complete this form.
Recommended method of contacting your colleague. Check all that apply:
Reason for Referral:

Peer Support Resources (for peer supporters only – password protected)

We extend our sincere appreciation to the to the Physician Health Program (PHP) and the Joint Collaborative Committee for their invaluable support