Your form "Client Referrals " has received the following response:
1/15/2019 13:34
Completion time: 36 min. 26 sec.

Client Name and Address		ANGELINA GUZMAN
				(806) 790-9962
				Client Email: denisegarciaguzman@gmail.com
				6109 7TH DR
				LUBBOCK
				TX
				79416
				Lubbock

Additional Client Information
Client's Age at Referral: 12
DOB: 12/5/2006
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? Yes
Does the Client Own or Rent their home? Own

Caretaker/Other Contact Information
DENISE GUZMAN    (806) 317-4522

Ramp Information
Where is the ramp needed? Front door
Description of obstacles(s): door threshold

Details of mobility
Power wheelchair  - she is quadriplegic and will remain this way rest of her life.

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

Referring Social Worker Information
Referring Social Worker Full Name: Tina M Kinsey, LVN
Name of Referring Agency: Superior Health Plan
Referring Social Worker's Phone: (800)218-7453
Referring Social Worker's Email: tina.kinsey@superiorhealthplan.com