Your form "Client Referrals " has received the following response: 
Submitted on: 04/08/2019 03:56:09 PM
Completion time: 45 min. 26 sec.

Client Name and Address
Kenneth Clay
806-632-8489
Client Email
105 Monroe Ave
TX
Lorenzo
79343
Crosby

Additional Client Information
Client's Age at Referral: 58
DOB: 10-30-1961
Client's Gender: Male
Client's Ethnicity: African American

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
Tameka Jacobx
806-632-8489

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
2 steps onto the porch and a threshold, no andrails

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.
Member is primarily wheelchair bound due to a stroke, can take a few steps with maximum assistance.  
Member lives in home with daughter whom is his caretaker

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

Referring Social Worker Information
Shonda Cummins
Name of Referring Agency: AMerigroup 
Referring Social Worker's Phone: 800-839-6275
Referring Social Worker's Email: shonda.cummins@amerigroup.com