Your form "Client Referrals " has received the following response: 
Submitted on: 04/24/2019 09:01:13 AM
Completion time: 22 min. 36 sec.

Client Name and Address
	Maria Lear
	(806) 500-5530
	Client's Email: R.
	2105 38th St
	TX
	Lubbock
	79412
	Lubbock

Client's Age at Referral: 56
DOB: 05-13-1962
Client's Gender: Female
Client's Ethnicity: Hispanic

Is this a hospice patient? No
Is this a dialysis patient? No
Is this a handicapped person living alone? Yes
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? Rent

Caretaker /Other Contact  Name:
Caretaker/Other Contact Phone:

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

Provide a brief description of the obstacle(s) (e.g. a door threshold, a single step, 
a mobile home with three steps, etc...) R. Steep steps, no railing to hold on to

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.
Prognosis is not expected to change

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

Referring Social Worker Information: Molly Kruse
Name of Referring Agency: Silver Star
Referring Social Worker's Phone: (806) 767-1707
Referring Social Worker's Email: mkruse@silverstar.org