Your form "Client Referrals " has received the following response:
11/14/2018 12:00
Completion time: 18 min. 29 sec.

Client Name and Address
	Jennifer Hogland
	(806) 891-5084
	Client Email

	3550 Horseshoe Road
	Levelland
	TX
	79336
	County
	Hockley

Additional Client Information
Client's Age at Referral: 42
DOB: 9/16/1976
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

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: Jonathan Hogland
Caretaker/Other Contact Phone: (806) 523-8148

Ramp Information
Where is the ramp needed? At the front/house entrance.
Description of obstacles(s): Sloped yard to front porch and one step from porch to front door.
Details of mobility
Consumer is in wheelchair and utilizes walker at time to navigate her environment. 
Diagnosed with ALS and is having to pull self into home using grab bars on the front 
door frame. Must fall into truck from porch and transfer using assistance to get back 
on porch from truck. Currently has a makeshift ramp made from dirt with a piece of metal 
grate covering dirt to add traction.

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

Referring Social Worker Information
Referring Social Worker Full Name: Jared Kendall
Name of Referring Agency: LIFE/RUN
Referring Social Worker's Phone: 806-891-5084
Referring Social Worker's Email: jared.kendall@liferun.org