Your form "Client Referrals " has received the following response: 
Submitted on: 01/28/2019 08:46:58 AM
Completion time: 6 min. 7 sec.

Client Name and Address		Jerry Hawlkins
				(806) 445-8608
				Client Email
				4105 E. 4th Street
				Lubbock 
				TX
				79403
				Lubbock

Client's Age at Referral: 55
DOB: 06-06-1963
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? Yes
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? Rent

Caretaker /Other Contact  Name: 
Caretaker/Other Contact Phone: 

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Front entrance and inside home in 2 places. 

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
Two steps up to front entrance with threshold, one step to laundry, and one step to back room. 

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 has leg amputation and requires the use of a wheelchair for mobility. 
Requires assistance to stand. 

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

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