Your form "Client Referrals " has received the following response: 
Submitted on: 05/28/2019 11:30:23 AM
Completion time: 5 min. 41 sec.

Client Name and Address
				Debra Barker
				806-507-5278
				Client Email: R. 
				1861 Grubstake Rd
				TX
				Levelland
				79336
				Hockley

Client's Age at Referral: 65
DOB: 03-26-1954
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? No
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? Own

Caretaker /Other Contact  Name: Jessica
Caretaker/Other Contact Phone: (806) 535-4327

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Back of the home which is the main entrance.

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
4 steps currently to enter and they are broken/unstable

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.
Patient walks short distances in her home but she will use her damaged wheelchair for 
long distances outside her home.

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

Referring Social Worker Full Name: Matthew Laughery
Name of Referring Agency: Covenant Health Partners
Referring Social Worker's Phone: (806) 725-7095
Referring Social Worker's Email: matthew.laughery@stjoe.org