Submitted on: 08/10/2019 03:00:56 PM
Completion time: 4 min. 52 sec.

Client Name and Address
				Antonio	Holguin
				(806) 762-2104
				Client Email
				9916 CR 6950
				TX
				Lubbock
				79403
				Lubbock

Client's Age at Referral: 53
DOB: 10-06-1965
Client's Gender: Male
Client's Ethnicity: Hispanic

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
Eustolia Holguin
(806) 781-3381

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
live in trailer, several 6-8 inch steps to get in the 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.
history of traumatic brain injury, now requires assistance with mobility including usage of walkers 
and wheelchairs, no change in mobility status likely

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

Referring Social Worker
Amber Young
South Plains Rehabilitation Hospital
(806) 507-3566
Amber.Young@encompasshealth.com