Your form "Client Referrals " has received the following response:
12/7/2018 10:07
Completion time: 7 min. 6 sec.

Client Name and Address
Ruby Adams
(806) 685-2808
Client Email

3006 4th Street
Plainview
TX
79072
County
Hale

Additional Client Information
Client's Age at Referral: 66
DOB: 12/6/1952
Client's Gender: Female
Client's Ethnicity: Caucasian
Is this a hospice patient? No
Is this a dialysis patient? No
Is this a handicapped person living alone? Yes
Did this person serve in the military? No

Client Financial Information
Is there a financial need, based on your agency's guidelines? No
Does the Client Own or Rent their home? Own

Caretaker/Other Contact Information
Caretaker /Other Contact  Name

Caretaker/Other Contact Phone

Ramp Information
Where is the ramp needed? Front door
Description of obstacles(s): The threshold is an obstacle and has two steep, narrow steps and no handrails.

Details of mobility
Patient walks with a walker for safety

Is there an existing dangerous ramp at the client's home?  No

Referring Social Worker Information
Referring Social Worker Full Name: Randall E Sheets MD
Name of Referring Agency: Texas Tech University Health Sciences Center-Family Medicine Clinic
Referring Social Worker's Phone: 806-743-2757
Referring Social Worker's Email: randall.sheets@ttuhsc.edu