All information is considered confidential. This information will be used by the Amputee Coalition to document the peer visit as well as to follow-up with amputees interested in being contacted by the Amputee Coalition. No personal information will be shared at any time.
Please complete and submit the electronic form below to report your peer visit. Optionally, you may mail, phone or fax your report. Click here to download a printable Certified Peer Visit Report Form (PDF).
Our NEW mobile Support & Outreach App is a convenient way to schedule and report peer visits as well as be directly connected with Visitees looking for peer support. CPVs can offer hope and encouragement from the comfort of their Android and iOS mobile devices from anywhere an internet connection is available. To learn more, please look for the App in the Google Play or Apple Store! You can also reach us with questions by emailing email@example.com.