Your form "Client Referrals " has received the following response:
3/29/2019 8:07
Completion time: 7 min. 57 sec.

Client Name and Address
Client First Name				Rebecca
Client Last 					Perez
Client Home Phone				(806) 466-1816
Client Email

Client Street					2711 Emory St
Client State					TX
Client City					Lubbock
Client Postal Code				79415
County						Lubbock
Additional Client Information
Client's Age at Referral			52
DOB						3/3/1967
Client's Gender					Female
Client's Ethnicity				Hispanic
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
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					Sister
Caretaker/Other Contact Phone					806-559-5996

Ramp Information
Where is the ramp needed? 					Ramp to front door
Description of obstacles(s): uneven sidewalk, steps

Details of mobility
member is W/C bound and uses electric scooter for mobility - 	
she is diabetic and has diabetic ulcers on her feet- 
member can not lift scooter over steps to get in front door.

Is there an existing dangerous ramp at the client's home?	No
Referring Social Worker Information
Referring Social Worker Full Name				Sharla Spencer RN
Name of Referring Agency					Amerigroup
Referring Social Worker's Phone					806-748-4880
Referring Social Worker's Email					sharla.spencer@amerigroup.com