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, or if you would like to refer a colleague for a support call.
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
I'm requesting a PSN call for:

myself someone else
If the request is for someone else, please list their name, email and phone number here. Then answer the questions below to the best of your knowledge.
Age

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

Man Woman Transgender/Nonbinary 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 for a call from a colleague about my own age:

Yes No preference
I prefer for a call from a colleague with the same gender as me:

Yes No preference
I prefer for a call from a colleague with my same role:

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

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

day evening nights flexible
Best way to be reached to find a common time for a call:

Email Text
Let us know if you would like the caller to specifically address 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.
Should be Empty: