Request a Peer Visit

We have 16 peer visitors who have been certified through the Amputee Coalition.  If you would like to request a peer visit for yourself or someone else, please complete and submit the following form or send an email to livinginmotion359@gmail.com:

Name(required)

Email(required)

Phone Number

Amputation Level

Date of Amputation

Age

What do you hope to get out of a peer visit?

Is there anything else you'd like to tell us about yourself?

Submit

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