LPF Peer Support Request Form

Limb condition was caused by:(Required)
My/their condition resulted in:(Required)
I am available:(Required)
How do you prefer to be initially contacted?(Required)
How did you hear about this program?


This waiver of liability includes any risk of attending space sessions, engaging in Skype or Zoom sessions, telephone calls, emails, or attending any events, workshops or other services provided by the Limb Preservation Foundation (“LPF”). Disclaimer: Peer Mentoring is not a substitute for professional mental health care or medical care. If you feel psychologically stressed to the point that it is interfering with your ability to function, please have the courage to seek the help you need in the form of a professional counselor, therapist and/or psychiatrist. I understand that the peer support services I will be receiving from my Mentor are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my Mentor is not acting as a mental health counselor or a medical professional I understand and agree that I am fully responsible for my well-being during my mentoring sessions, and subsequently, including my choices and decisions. I understand that mentoring is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or medical treatment, and I will not use it in place of any form of therapy. I understand that all comments and ideas offered by a Peer Support Mentor are solely for the purpose of aiding me in achieving my defined goals in order to improve or enhance my mental wellbeing throughout my recovery journey. I understand that my mentor will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if my mentor is ordered by a court to provide information or to testify, she will do so to the extent the law requires. I understand that the use of technology is not always secure and I accept the risks of confidentiality in the use of email, text, phone, Skype, Zoom, and other technology. I hereby release, waive, acquit and forever discharge my mentor(s) and LPF, and its employees, agents, directors, officers, successors, assigns, personal representatives, executors and heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my mentor(s) as a result of the advice given by my mentor(s) or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.
Waiver of Liability Agreement(Required)