Your form "Client Referrals " has received the following response: 
Submitted on: 03/29/2019 03:14:59 PM
Completion time: 8 min. 10 sec.

Client Name and Address
	Blanca Gutierrez
	(806) 300-3671
	334 S Durham
	TX
	Crosbyton
	79322
	Crosby

Additional Client Information
Client's Age at Referral: 61
DOB: 03-28-1958
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

Client Financial Information
Is there a financial need, based on your agency's guidelines? No
Does the Client Own or Rent their home? Own

Caretaker/Other Contact Information
Alma Gutierrez
(806) 300-3671

Where is the ramp needed?
at the front of the home has 2-3 steps

Provide a brief description of the obstacle(s) 
porch has 2-3 steps and sidewalk is not safe to use assistive walking device

Provide details of the client's mobility that are relevant to a ramp 
client uses rollator

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

Referring Social Worker Information
	Lisa Gonzales
	SPAG- Area Agency on Aging
	(806) 687-0940
	lgonzales@spag.org