Your form "Client Referrals " has received the following response:
Submitted on: 05/08/2019 09:20:19 AM
Completion time: 36 min. 52 sec.

Client Name and Address
				Patricia Kirby
				(806) 766-3557
				pattyskingdom@yahoo.com
				5003 40th Steet
				TX
				Lubbock
				79414	
				Lubbock

Client's Age at Referral: 61
DOB: 10-28-1957
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? Rent

Caretaker /Other Contact  Name
Caretaker/Other Contact Phone (806) 795-5433

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...) 
Front porch with one step (about 18-24" rise total), threshold wedge may be 
needed from the porch into 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.
The client has multiple diagnoses that cause mobility complications including 
back pain, osteoporosis, and has had knee surgery. Currently using a cane to 
maneuver environment.

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