Your form "Client Referrals " has received the following response:
1/3/2019 16:14
Completion time: 17 min. 25 sec.

Client Name and Address
Slyvia Banda
 361-489-5388
Client Email

2716 Cornell St
Luboock
TX
79415
County
Lubbock

Additional Client Information
Client's Age at Referral: 62
DOB: 6/23/1956
Client's Gender: Female
Client's Ethnicity: Other

Is this a hospice patient? No
Is this a dialysis patient? Yes
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

Caretaker/Other Contact Phone

Ramp Information
Where is the ramp needed? Ramp is needed in the front of the home.
Description of obstacles(s): 
Pt lives with her son at his home. The porch consist of a large step the patient must 
overcome when leaving or entering the home.

Details of mobility
The patient usually utilizes a wheelchair but will occasionally use a walker. She can't use either 
when stepping up onto the porch or stepping down off of the porch. She requires assistance from someone when doing so.

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

Referring Social Worker Information
Referring Social Worker Full Name: Lori Amin
Name of Referring Agency: Fresenius Kidney Care
Referring Social Worker's Phone: (806) 793-1414
Referring Social Worker's Email: lori.amin@fmc-na.com