Your form "Client Referrals " has received the following response: 
Submitted on: 03/29/2019 11:33:22 AM
Completion time: 30 min. 45 sec.

Client Name and Address
				David Lechuga
				(806) 928-7425
				Client Email
				115 E 11th Street
				TX
				Post
				79356
				Post


Additional Client Information
Q. Client's Age at Referral: 70
DOB: 07-10-1948
Client's Gender: Male
Client's Ethnicity: Caucasian

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: Patti Lechuga
Caretaker/Other Contact Phone: (806) 928-7425

Where is the ramp needed? (Be specific: front of house, side door, etc...)
The ramp is needed in the door way to assist patient with getting in and out of the house

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
There are steps that prevent patient from being able to go in and out of the house, 
and the ramp patient did have is dilapidated and wood is falling apart.

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.
Pt has a manual wheel chair, and has double amputation of legs, and is needing a ramp to be mobile 
and get to appointments

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

Referring Social Worker Full Name: Heather Menasco
Name of Referring Agency: Kidney Center of Lubbock
Referring Social Worker's Phone: (806) 771-9933
Referring Social Worker's Email: heather.menasco@usrenalcare.com