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Physician Health Program Intake Form

NOTE:

Due to technical difficulties, we did not receive any Physician Health Program online intake forms submitted between July 15 and July 22.

If you submitted an intake form during this period, we kindly ask that you resubmit your form below or call our intake line at 204−237−8320 or 844−433−3762 (toll free). We apologize for any inconvenience and appreciate your understanding.

Welcome to the confidential online Doctors Manitoba Physician Health Program Online Intake. We offer inclusive, collaborative, and trauma-informed therapeutic and peer support services for both individuals and couples. No matter what's impacting your psychological or emotional health, we're here to help. Please complete the form below, and a Physician Health Program clinician will contact you within 24 hours to schedule an appointment.

Please tell us a little about yourself.

  • Please Select...
  • Medical Student
  • Resident
  • Practising Physician
  • Retired Physician
  • MLPIMG Participant
  • Spouse of a DRMB Member
  • Spouse of a MLPIMG Participant
  • DRMB Member Dependent (18 or over)
  • DRMB Member Dependent (between 12 and 17)


If you are a spouse or dependent, please indicate DRMB Member or MLPIMG participant you are connected to. This is required to confirm eligibility for services only. No one will contact the member or MLPIMG participant.

Member or MLPIMG Participant's name

Please provide the best phone number where we can reach you.
Please provide the best email address where we can reach you.
Please check any that apply.
OPTIONAL: Please describe your reason(s) for seeking support at this time. 

If you are in crisis and in need of immediate assistance, help is available by: 

  • calling Klinic Crisis Line at 204−786−8686 (24−7) or 1−888−322−3019 (24−7)
  • by calling/​texting 988 for the Suicide Crisis Helpline (24−7)
  • going to the Crisis Response Centre at 817 Bannatyne Avenue in Winnipeg or proceed to the nearest Emergency department outside of Winnipeg.
Need help?