Your form "Client Referrals " has received the following response: 
Submitted on: 07/23/2019 09:09:51 AM
Completion time: 14 min. 9 sec.

Client Name and Address		CONNIE DELEON
				(806) 470-0403
				Client Email
				P.O. BOX 41
				HALE CENTER
				TX
				79041
				Hale

Client's Age at Referral: 90
DOB: 04-04-1929
Client's Gender: Female
Client's Ethnicity: Hispanic

Is this a hospice patient? Yes
Is this a dialysis patient? No
Is this a handicapped person living alone? Yes
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
LINDA/ DAUGHTER		(806) 470-0403

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) SIDE DOOR
Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
TWO STEP HOUSE
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.
WHEEL CHAIR, AND ON HOSPICE

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

Referring Social Worker Information
KRISANN SCHULZ/ PRIMARY CARE PHYSICIAN
WEST TEXAS FAMILY MEDICINE
(806) 288-7891
mechellepena36@gmail.com