Your form "Client Referrals " has received the following response: 
Submitted on: 07/12/2019 01:37:34 PM
Completion time: 10 min. 10 sec.

Client Name and Address 	Ernest Perez
				(806) 559-2707
				Client Email
				17006 COUNTY ROAD 2220
				TX
				Lubbock
				79423
				Lubbock

Client's Age at Referral: 61
DOB: 06-21-1958
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

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
Felix Perez		(806) 559-2707

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
In 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. Brother built a ramp, but it is not stable and no rails.

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.
Client is bed bound. Had one leg amputated and back surgery which left him with partial paralysis.

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

Referring Social Worker Full Name: Esmeralda Varela(Not licensed SW)
Name of Referring Agency: Adult Protective Services
Referring Social Worker's Phone: (806) 773-1549
Referring Social Worker's Email: esmeralda.varela@dfps.state.tx.us