Temple Peer Support Network Request

Temple Peer Support Network Request

Sign up here if you need support and would like a colleague to reach out for a short phone call to check in with you.
Please note: The Temple Peer Support Network (PSN) is a wellness initiative to promote camaraderie and connectedness between providers. It is a peer support program, not a mental health program. Participants who identify a mental health need to their peer support person will be directed to access mental health services through the employee assistance program (EAP) by calling 1-800-437-0911.
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Age

20-40 years old 41-60 years old >61 years old
Gender Identity

Man Woman Non-binary/Non-conforming Prefer not to respond
Role

Resident - intern Resident - mid or senior Fellow APP (PA, NP etc) faculty - assistant professor faculty - associate professor faculty - professor
Department

anesthesia internal med internal med subspecialty family med emergency med surgery - general/trauma surgery - subspecialty neuro neurosurgery OB/GYN ophtho ortho ENT PM&R podiatry psychiatry radiology urology pathology
I prefer to have a colleague about my own age:

Yes No preference
I prefer to have a colleague with the same gender identity as me:

Yes No preference
I prefer to have a colleague with my same role:

Yes As close to my role as possible No preference
I prefer to have a colleague from:

Within my department Outside my department No preference
Best times for me to receive a call (pick any that apply):

day evening nights flexible
Best way to reach me to find a common time for a call:

Email Text
Let us know if you would like to speak to someone specifically about one of the following topics:

diversity, equity & inclusion women in medicine parenting or other family obligations NA
Please leave any other comments here:
Please expect a colleague to reach out within the next 3 business days. If you need support sooner, please call the employee assistance program (EAP) at 1-800-437-0911.
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