Your form "Client Referrals " has received the following response: 
Submitted on: 06/05/2019 01:05:32 PM
Completion time: 12 min. 3 sec.

Client Name and Address
				Rudy Ochoa
				(806) 445-9616
				Client Email
				2604 40th Street
				TX
				Lubbock
				79413
				Lubbock

Additional Client Information
Client's Age at Referral: 66
DOB: 04-12-1953
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
Belinda Ochoa
(806) 724-4011

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) 
front of house at entryway. 

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
three steps to enter without handrail

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.
Patient has had a recent heart attack and coronary artery bypass graft (x3) resulting 
in diminished ability to ambulate and manipulate the stairs. Patient is able to propel 
self using wheelchair. 

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

Referring Social Worker Information
Michelle Reyes
Trustpoint Rehabilitation Hospital
(806) 740-8559
michelle.reyes@ernesthealth.com