Your form "Client Referrals " has received the following response:
12/27/2018 15:25
Completion time: 14 min. 51 sec.

Client Name and Address
Reynaldo Esquivel
(806) 729-2236
Client Email

1210 Joliet
Plainview
TX
79072
County
Hale

Additional Client Information
Client's Age at Referral: 79
DOB: 8/5/1939
Client's Gender: Male
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

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: Ernesto Esquivel
Caretaker/Other Contact Phone: 806-729-8126

Ramp Information
Where is the ramp needed? front of house
Description of obstacles(s): single step and door threshold

Details of mobility
Both client and spouse have to use walkers at this time.  Spouse uses a manual wheelchair a lot.  
Due to age and condition, this is not expected to change and may get worse.

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

Referring Social Worker Information
Referring Social Worker Full Name: Phyllis Suber-Raper
Name of Referring Agency: Texas Health and Human Services
Referring Social Worker's Phone: 806-296-3145
Referring Social Worker's Email: phyllis.suber-raper@hhsc.state.tx.us