Your form "Client Referrals " has received the following response:
Submitted on: 05/23/2019 03:21:46 PM
Completion time: 5 min. 23 sec.  10/5/2020 - 12:50 - # not working

Client Name and Address		Willie Floyd
				(806) 747-0318
				Client Email
				3012 East 2nd Place
				TX
				Lubbock
				79403
				Lubbock
Client's Age at Referral: 78
DOB: 10-22-1940
Client's Gender: Female
Client's Ethnicity: African American

Is this a hospice patient? No
Is this a dialysis patient? Yes
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? Own

Caretaker/Other Contact Information
Angela Floyd (806) 466-3499

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door,etc...)
The ramp is needed in the front of the house

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
Door threshold.

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.
Ms. Floyd uses a manual wheelchair.

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

Referring Social Worker Information
Shelby Westerman
South Plains Dialysis Center of Lubbock New Job: 
(806) 793-1414
Shelby.Westerman@fmc-na.com