Your form "Client Referrals " has received the following response: 
Submitted on: 01/28/2019 08:58:18 AM
Completion time: 6 min. 53 sec.

Client Name and Address
Riley Jernigan
(806) 863-3116
Client Email R. 

Client Street: 5748 150th
Client City: Lubbock 
Client State: TX
Client Postal Code: 79424
County: Lubbock

Client's Age at Referral: 67
DOB: 11-08-1951
Client's Gender: Male
Client's Ethnicity: Other

Is this a hospice patient? No
Is this a dialysis patient? Yes
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
Caretaker/Other Contact Phone

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
At the front entrance.

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
Mobile home with concrete steps (3) to front entrance. Platform needed to allow for 
wheelchair turning and entrance into 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.
Consumer has multiple diagnosis that make it difficult for him to use stairs including 
lower back injury, CHF, and Arterial Fibrillation. 

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

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