Your form "Client Referrals " has received the following response: 
Submitted on: 01/28/2019 08:17:37 AM
Completion time: 11 min. 14 sec.

Client Name and Address
	Katherine Neves
	(806) 632-7915
	kathrineneves7915@icloud.com
	2505 33rd Street 
	Lubbock
	TX
	79410
	Lubbock

Client's Age at Referral: 49
DOB: 04-18-1969
Client's Gender: Female
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

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
Caretaker/Other Contact Phone

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
At the front and back entrance 

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
Small porch area with indirect entrance, two steps, and threshold. 

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.
Consumer was injured during surgery and is currently diagnosed as being 
quadriplegic. She uses a manual wheelchair, however, she is requesting 
assistance and is due to receive an electric wheelchair. She is able to 
stand and transfer in certain situations with the assistance of transfer 
boards and other assistance. 

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

Referring Social Worker Full Name: Jared Kenda;;
Name of Referring Agency: LIFE/RUN
Referring Social Worker's Phone: (806) 795-5433
Referring Social Worker's Email: jared.kendall@liferun.org