Your form "Client Referrals " has received the following response: 
Submitted on: 06/11/2019 08:12:47 AM
Completion time: 3 min. 31 sec.

Client Name and Address
				Linda Hilton
				(806) 407-2008
				Client Email
				9408 N Dixon Ave
				TX
				Lubbock
				79415
				Lubbock

Client's Age at Referral: 73
DOB: 07-12-1945
Client's Gender: Female
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? No

Is there a financial need, based on your agency's guidelines? Yes
Does the Client Own or Rent their home? Own

Caretaker /Other Contact  Name
Terry Gill
(682) 936-0645

Ramp Information
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...) 
5 steep steps into mobile home

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.
having frequent falls, using walker at this time, but in process of getting a wheelchair

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

Referring Social Worker Information
Jill Barnwell RN, BSN, CCM, CMC
Name of Referring Agency: Humana
Referring Social Worker's Phone: (806) 236-5861
Referring Social Worker's Email: jbarnwell1@seniorbridge.com