Your form "Client Referrals " has received the following response: 
Submitted on: 04/30/2019 09:24:17 AM
Completion time: 9 min. 20 sec.

Client Name and Address
	Robert Armstrong III
	(806) 241-7059
	Client Email: R.
	3517 35th St Apt B 
	Lubbock TX 79713
	TX
	Lubbock
	79413
	Lubbock

Client's Age at Referral: 40
DOB: 12-16-1978
Client's Gender: Male
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

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

Caretaker /Other Contact  Name Yvonne Davidson
Caretaker/Other Contact Phone 806-407-4518

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
2 front porch ramps, one from front door to porch and one for porch to ground

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
2 front porch ramps, one from front door to porch and one for porch to ground

Provide details of the client's mobility that are relevant to a ramp 
(e.g. walking, assisted walking, manual wheelchair, powered wheelchair, etc.). 
Also include a prognosis if this is expected to change.
Mbr is a Quadriplegic -Member requires assistance with ADL/IADLs d/t paralysis 
of hands and from the chest down r/t partial Quadriplegia, Member with paralysis,
WC dependent, requires safe access for transfers in, and for entering and leaving 
home. Prevents falls and injury

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

Referring Social Worker Information: Samantha Wilbanks LVN 
Name of Referring Agency: Amerigroup
Referring Social Worker's Phone: (806) 748-4880
Referring Social Worker's Email: samantha.wilbanks@amerigroup.com