Your form "Client Referrals " has received the following response: 
Submitted on: 08/15/2019 10:15:53 AM
Completion time: 40 min. 48 sec.

Client Name and Address		Sylvia Lopez
				(806) 587-4531
				Client Email
				709 W 22nd St 
				Plainview, TX 79072
				TX
				Plainview
				79072
				Hale

Additional Client Information
Client's Age at Referral: 62
DOB: 03-05-1957
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? Own

Caretaker/Other Contact Information
Caretaker /Other Contact  Name
Caretaker/Other Contact Phone: (806) 748-4880

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Mbr is requesting a ramp to exit the back of her home

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
Mbr has 2 steps and is unsafe for her to go down them with her walker 

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.
Mbr uses a walker 

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

Referring Social Worker Information
Samantha Wilbanks
Amerigroup
(806) 748-4880
samantha.wilbanks@amerigroup.com