Your form "Client Referrals " has received the following response: 
Submitted on: 06/23/2019 12:47:25 PM
Completion time: 4 min. 3 sec.

Client Name and Address
				Darlene Eller 
				(806) 667-3865
				Client Email
				1007 Ave H 
				TX
				Petersburg 
				79250
				Hale
				County: Hale

Client's Age at Referral: 74
DOB: 01-23-1945
Client's Gender: Female
Client's Ethnicity: Caucasian

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? No
Does the Client Own or Rent their home? Own

Caretaker /Other Contact  Name: Belinda Summerford 
Caretaker/Other Contact Phone: (806) 667-3865

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Patient has a ramp that needs to be repaired in 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...) 
Old ramp, needs repair 

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.

Patient uses a rollator walker, CM ordered wheelchair at DC 

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

Referring Social Worker
Melissa Garcia 
Covenant Medical Center case management 
(806) 782-7873
melissa.garcia2@stjoe.org