Doctors Manitoba | PAR Intake Form

Welcome to the confidential online Physicians At Risk (PAR) program intake. PAR offers 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 PAR clinician will contact you within 24 hours to schedule an appointment.

Topic *

I am a:

First Name *

Last Name *

If you are a spouse or dependent over 18, 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

First Name *

Last Name *

Please provide the best phone number where we can reach you.

Phone Number *

Can we leave a voicemail at this number? *

Yes

What is the best time of day to reach you? *

Mornings

Afternoons

Evenings

Anytime

Message

OPTIONAL: Please describe your reason(s) for seeking support at this time.

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