Your form "Client Referrals " has received the following response: 
Submitted on: 03/11/2019 10:44:08 AM
Completion time: 16 min. 5 sec.

Client Name and Address
	GLENDYN DEVLIN
	(806) 787-0986
	Client Email
	5814 98th St 
	TX
	Lubbock	
	79424
	Lubbock

Additional Client Information
Client's Age at Referral: 83
DOB: 04-29-1935
Client's Gender: Female
Client's Ethnicity: Other

Is this a hospice patient? No
Is this a dialysis patient? No
Is this a handicapped person living alone? Yes
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? Rent

Caretaker /Other Contact  Name: Shireen Clark- daughter
Caretaker/Other Contact Phone: R. 

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
bathtub rails

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
fell a couple times and can't step up in the shower. Need a hand rails

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.
Currently using a walking and cane but mostly a walker 

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

Referring Social Worker Information
Q. Referring Social Worker Full Name: Katya Amina
Name of Referring Agency: Aetna Community Care
Referring Social Worker's Phone: (682) 261-1087
Referring Social Worker's Email: aminak@aetna.com