Peer Support for You

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To speak with a Peer Supporter, please fill out the form below. Your information and use of the program will be kept private & confidential – only viewable by the Peer Supporter and program administrator for the purpose of facilitating a match.

Your Peer Supporter will reach out to you as soon as possible, generally within 24 - 72 hours.

If you have any questions, please contact elkvalleyphysicians@gmail.com

Need urgent assistance? Contact Doctors of BC Physician Health Program 24/7 line: 1-800-663-6729

Email *

Your Name: *

Preferred Phone Number: *

Preferred method of contact: *

Phone call

Text

Required

Preferred modality of peer support: *

Video call

Phone call

In-person

Required

Best time of day to contact you: *

Mornings (before 12 pm)

Afternoons (12 -5 pm)

Evenings (After 5 pm)

Other:

Required

Preferred location of the physician peer supporter matched with you:

Within Fernie

Outside Fernie, within the East Kootenay Region

Outside the East Kootenay Region

Clear selection

Reason(s) for referral: Select 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 (e.g. related to race, gender identity, sexual orientation, physical ability or other) from patients, colleagues, or staff

Prefer not to say

Other:

Required

Are there any factors you would like us to consider when we match you with a peer supporter? Please let us know if it would help if your peer supporter has a particular lived experience (ex. identifies as a woman, BIPOC (Black, Indigenous, Person of Colour), 2SLGBTQIA+, rural vs. urban locations, etc.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.