Your form "Client Referrals " has received the following response: 
Submitted on: 08/22/2019 02:25:01 PM
Completion time: 5 min. 46 sec.

Client Name and Address 	Abcde Chavez
				(806) 448-1690
				Client Email R. 
				1513 10th Sst 
				TX
				Levelland
				79336
				Hockley

Client's Age at Referral: 16
DOB: 02-26-2003
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? Yes
Does the Client Own or Rent their home? Own

Caretaker /Other Contact 
Modesta Chavez         (806) 448-1690

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Font of 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 patient confined to a wheel chair and unable to get the wheel chair in the home 

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.
The patient has Scoliosis and limited mobility and is confined to a wheel chair

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

Referring Social Worker 
Jessica Rodriguez
Larry Combest Community Wellness Center
(806) 743-2327
jessi.rodriguez@ttuhsc.edu