Your form "Client Referrals " has received the following response:
12/5/2018 11:37
Completion time: 5 min. 38 sec.

Client Name and Address
James Conner
806-632-1113
Client Email

500 E 17th St
Littlefield
TX
79339
County
Lamb

Additional Client Information
Client's Age at Referral: 71
DOB: 9/28/1947
Client's Gender: Male
Client's Ethnicity: Caucasian

Is this a hospice patient? Yes
Is this a dialysis patient? No
Is this a handicapped person living alone? No
Did this person serve in the military? Yes

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
Caretaker /Other Contact  Name: Karen Conner
Caretaker/Other Contact Phone: 806-632-1113

Ramp Information
Where is the ramp needed? The front door
Description of obstacles(s): Single step into the door from what I remember.

Details of mobility
Pt has terminal cancer and has become so weak now to the point that he requires a 
wheelchair the majority of the time.

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

Referring Social Worker Information
Referring Social Worker Full Name: Gena Sams
Name of Referring Agency: Kindred Hospice
Referring Social Worker's Phone: 806-748-1041
Referring Social Worker's Email: Gena.sams@kindredhospicecare.com