CPV Report Form

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).

Amputee Coalition Support App
The Amputee Coalition Support App is a free app initially designed to provide Certified Peer Visitors with a convenient way to schedule and report peer visits. Enhanced app features, like in-app texting and in-app video chatting, help connect CPVs directly with individuals and families who looking for peer support along their journey with limb loss or limb difference. CPVs can offer support, hope and encouragement within this HIPAA-compliant app from the comfort of their Android and iOS mobile devices, or from anywhere an internet connection is available.

Support & Outreach App

To learn more, please download the Amputee Coalition Support App from the Apple App StoreGoogle Play, or web browser link: https://cpvapp.amputee-coalition.org. For Support App questions and technical assistance, please email the Amputee Coalition Peer Support Team at peersupport@amputee-coalition.org.

App Store Google Play