Your form "Client Referrals " has received the following response: 
Submitted on: 07/26/2019 11:27:31 AM
Completion time: 10 min. 1 sec.

Client Name and Address		Bowie Oden
				(806) 832-0162			
				Client Email
				405 Clovis Rd Unit 17
				TX
				Shallowater
				79363
				Lubbock

Client's Age at Referral: 66
DOB: 01-27-1953
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? 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: n/a
Caretaker/Other Contact Phone: 806-832-0162

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Mbr has ramp just needing a few repairs done to the lose boards on ramp causing safety hazard

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
member is the homeowner and has a ramp needing some repairs , 
2 of the boards are warped and lose causing a safety hazard 

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 cane and walker , has right sided weakness due to stroke. 
mbr needing repairs to safely enter and exit home

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

Referring Social Worker Information
Denise Cardenas
Amerigroup
(806)748-4880
denise.cardenas@amerigroup.com