Your form "Client Referrals " has received the following response:
1/9/2019 12:19
Completion time: 4 min. 28 sec.

Client Name and Address
				Bruce Hilliard
				(806) 778-0797
				Client Email
				1904 60th St
				Lubbock
				TX
				79412
				County
				Lubbock

Additional Client Information
Client's Age at Referral: 48
DOB: 9/10/1970
Client's Gender: Male
Client's Ethnicity: African American

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
Caretaker /Other Contact  Name

Caretaker/Other Contact Phone

Ramp Information
Where is the ramp needed? Front door entry
Description of obstacles(s): Patient has a single level home with 2 entry steps.

Details of mobility
Patient is new amputee. Has 2 entry steps into front door. Patient is limited with hopping at this time. 
Will discharge from out hospital at wheelchair level.

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

Referring Social Worker Information
Referring Social Worker Full Name: Danielle Cooper, LMSW
Name of Referring Agency: Trustpoint Rehab Hospital
Referring Social Worker's Phone: 806-740-8560
Referring Social Worker's Email: daniellecooper@ernesthealth.com