Your form "Client Referrals " has received the following response: 
Submitted on: 05/03/2019 04:49:05 PM
Completion time: 4 min. 17 sec.

Client Name and Address
	Olivia Cantu
	(806) 407-7235
	Client Email: R.
	2822 Dartmouth Street
	TX
	Lubbock
	79415
	Lubbock

Client's Age at Referral: 66
DOB: 04-07-1953
Client's Gender: Female
Client's Ethnicity: Hispanic

Is this a hospice patient? Yes
Is this a dialysis patient? Yes
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? No
Does the Client Own or Rent their home? Own

Caretaker /Other Contact  Name
Caretaker/Other Contact Phone

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Font of house has steep steps and member having difficulty getting down to 
attend frequent doctor appointments

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
Steep steps with no rail for assistance

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.
Walking, uses walker when weak

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

Referring Social Worker Information
Jill Barnwell, RN, BSM, CCM, CMC
Humana
(806) 236-5861
jbarnwell1@seniorbridge.com