Your form "Client Referrals " has received the following response:
12/18/2018 11:45
Completion time: 19 min. 47 sec.

Client Name and Address
Raymondo Mendez
(806) 729-7738
Client Email
ericasoto2@gmail.com
103 E 14th ST
Abernathy
TX
79311
County
Hale

Additional Client Information
Client's Age at Referral: 16
DOB: 3/4/2002
Client's Gender: Male
Client's Ethnicity: Hispanic
Is this a hospice patient? No
Is this a dialysis patient? No
Is this a handicapped person living alone? No
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: Erica Perez (Mother)
Caretaker/Other Contact Phone: (806) 729-7738

Ramp Information
Where is the ramp needed? In front of the sliding door in Garage
Description of obstacles(s): The area that goes down into the garage is steep and is used as our 
entryway into the house. The threshold sits about 2 feet above the ground.

Details of mobility
Raymondo is not able to ambulate on his own, has to use manual wheelchair. He will be getting a 
powered scooter on December 28th. This is due to his Congestive Heart Failure , Osteoporosis, and Compressed Spinal Fractures.

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

Referring Social Worker Information
Referring Social Worker Full Name: Lisa Zajicek, LMSW
Name of Referring Agency: Palliative Care out patient Clinic - JACC
Referring Social Worker's Phone: 806-725-4676
Referring Social Worker's Email: lisa.zajicek@stjoe.org