Your form "Client Referrals " has received the following response: 
Submitted on: 01/28/2019 08:26:41 AM
Completion time: 7 min. 9 sec.

Client Name and Address
				Donald Hallett 
				(806) 893-0595
				Client Email R. 
				218 Maple Street
				Levelland
				TX
				79336
				Hockley

Additional Client Information
Client's Age at Referral: 72
DOB: 05-15-1946
Client's Gender: Male
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? Yes

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 R. 
Caretaker/Other Contact Phone R. 

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Front of house

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

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.
Consumer wears brace on right leg and is able to walk with and without cane at times. 
difficulties stepping up and down due to needed brace and weak muscles.

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

Referring Social Worker Full Name: Jared Kendall
Name of Referring Agency: LIFE/RUN
Referring Social Worker's Phone: (806) 795-5433
Referring Social Worker's Email: jared.kendall@liferun.org