Your form "Client Referrals " has received the following response: 
Submitted on: 01/17/2019 04:45:31 PM
Completion time: 5 min. 23 sec.

Client Name and Address
Lewis Mcmahan
(806) 283-1427
Client Email

6201 19th st space 62
Lubbock
TX
79407
Lubbock

Client's Age at Referral 68
DOB 11-05-1950
Client's Gender Male
Client's Ethnicity Caucasian
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

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Front of home 
Provide a brief description of the obstacle(s) (e.g. a door threshold, a single step, 
a mobile home with three steps, etc...) Mobile home with steps 
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.
Significant vascular disease which causes pain going up the steps. 
He is also at risk for falling due to weakness in legs

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

Referring Social Worker Information
Referring Social Worker Full Name: Amanda Bull
Name of Referring Agency: Caprock Cardiovascular Center
Referring Social Worker's Phone: 8067015858
Referring Social Worker's Email: abull@caprockcardio.com