Your form "Client Referrals " has received the following response: 
Submitted on: 06/06/2019 04:06:49 PM
Completion time: 18 min. 4 sec.

Client Name and Address
Roberta Legrand
806-831-5325
belmmar009@gmail.com
116 N AVE S
TX
Post
79356
Garza

Additional Client Information
Client's Age at Referral: 69
DOB: 12-21-1949
Female

Client's Ethnicity: African American
Is this a hospice patient? No
Is this a dialysis patient? Yes
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? Own

Caretaker/Other Contact Information
Belinda Martin
512-656-9130

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Front 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...)
Door threshold, 2 steps and one step down a porch. 
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.
She uses a manual wheelchair. 

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

Referring Social Worker Information
Shelby Westerman
Fresenius Dialysis Center-Redbud
806-785-6285
Shelby.Westerman@fmc-na.com