Your form "Client Referrals " has received the following response: 
Submitted on: 09/23/2019 01:32:45 PM
Completion time: 8 min. 51 sec.

Client Name and Address		Cleotilde Dominguez
				(806) 548-7805
				Client Email R. 
				1118 32ND ST
				Lubbock
				TX
				79411
				Lubbock

Client's Age at Referral: 89
DOB: 04-14-1930
Client's Gender: Female
Client's Ethnicity: Hispanic

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

Is there a financial need, based on your agency's guidelines? Yes
Does the Client Own or Rent their home? Rent

Caretaker /Other Contact 
Noe Dominguez         (806) 548-7805

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
There is a high concrete porch with two steps and no 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.
Client uses a walker and is at risk for falls.

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

Referring Social Worker Full Name: Esmeralda Varela (not a SW)
Name of Referring Agency: Adult Protective Services
Referring Social Worker's Phone: (806) 773-1549
Referring Social Worker's Email: esmeralda.varela@dfps.state.tx.us