Your form "Client Referrals " has received the following response: 
Submitted on: 07/25/2019 09:52:08 AM
Completion time: 15 min. 5 sec.

Client Name and Address
				Patricia Brewer
				(806) 239-5571
				Client Email
				2406 94th Street
				TX
				Lubbock
				79423
				Lubbock

Additional Client Information
Client's Age at Referral: 66
DOB: 06-21-1953
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

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
Leslie Brewer  (806) 773-2454

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...)
Front door

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
one step between 4-6 inches at front door

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 has manual wheelchair

Is there an existing dangerous ramp at the client's home? R. 

Referring Social Worker Information
Amber Young
Name of Referring Agency: South Plains Rehab Hospital
Referring Social Worker's Phone: 806-507-3566
Referring Social Worker's Email: Amber.Young@encompasshealth.com