Your form "Client Referrals " has received the following response: 
Submitted on: 11/30/2018 11:15:02 AM
Completion time: 38 min. 24 sec.

Client Name and Address
			Levi Almanza
			(806) 392-7562
			jessicafuentes99@gmail.com

			1919 62nd St
			Lubbock 
			TX
			79412
			County Lubbock

			Client's Age at Referral 4
			DOB 08-01-2014
			Client's Gender Male
			Client's Ethnicity Hispanic
			Is this a hospice patient? No
			Is this a dialysis patient? No
			Is this a handicapped person living alone? No
			Did this person serve in the military? No

			Client Financial Information
			Is there a financial need, based on your agency's guidelines? Yes
			Does the Client Own or Rent their home? Own

			Caretaker/Other Contact Information
			Caretaker /Other Contact  Name Jessica Fuentes (mother)
			Caretaker/Other Contact Phone (806) 392-7562

			Ramp Information
			Where is the ramp needed? Front of the house

Provide a brief description of the obstacle(s) 
Small porch with a step down from the front door and step down from the porch.

Provide details of the client's mobility that are relevant to a ramp 
Member is wheelchair bound due neurological disease.  

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

Referring Social Worker Information
Referring Social Worker Full Name Irma Hernandez LVN
Name of Referring Agency Superior Health Plan-Star Kids 
Referring Social Worker's Phone 844-433-2074
Referring Social Worker's Email irma.hernandez2@superiorhealthplan.com