Your form "Client Referrals " has received the following response: 
Submitted on: 03/11/2019 11:03:27 AM
Completion time: 9 min. 58 sec.

Client Name and Address
				Jessica Phillips 
				(806) 897-0402
				Client Email: R. 
				402 Austin
				TX
				Levelland
				79336
				Hockley

Client's Age at Referral: 45
DOB: 01-05-1974
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? 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  Name: Joanna
Caretaker/Other Contact Phone: (806) 891-1134

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
needed for side and/or front of home.  There are stairs at both entrances. 
Front may have more room for ramp than the side of the house 

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
Patient has 3 steps at both entrances of home, is a pier and beam home. 

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 a long history of seizures and is unsafe to walk due to frequency of seizures, 
patient uses wheelchair as her primary mobility and lives with her elderly mother who is 
unable to assist patient with keeping wheelchair down multiple steps.  Patient has a provider 
who has attempted to assist patient down steps without wheelchair and patient has fallen.  
Patient's goal is get outside as she is confined to her home due to risks for falls due to steps. 

Is there an existing dangerous ramp at the client's home? No

Referring Social Worker Full Name:  Allison Seifert
Name of Referring Agency: Caprock Home Health SErvices 
Referring Social Worker's Phone: (505) 459-5507
Referring Social Worker's Email: allison.seifert@chhsi.com