Your form "Client Referrals " has received the following response: 
Submitted on: 07/11/2019 09:19:24 AM
Completion time: 10 min. 43 sec.  Called 12:46 10/5/2020 - # busy

Client Name and Address 	Rosy Casias
				(806) 466-4332
				Client Email
				3702 AVENUE J
				TX
				Lubbock
				79412
				Lubbock

Client's Age at Referral: 66
DOB: 02-09-1953
Client's Gender: Female
Client's Ethnicity: Hispanic

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

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
Jimmy Casias		(806) 466-4332

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
The door threshold and a single step need to be cleared with the wheelchair. 

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.
Ms. Casias uses a manual wheelchair to come to dialysis. 
She has been struggling to get in and out of the house without a ramp. 

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

Referring Social Worker Information
 Shelby Westerman
 Referring Agency: South Plains of Lubbock Dialysis Center
 Referring Social Worker's Phone: (806) 793-1414
 Referring Social Worker's Email: Shelby.Westerman@fmc-na.com