Your form "Client Referrals " has received the following response: 
Submitted on: 04/08/2019 02:16:05 PM
Completion time: 13 min. 32 sec.

Client Name and Address
	Sandra Prince
	(806) 368-0302
	Client Email R. 
	6801 W. 19th, Space 262
	TX
	Lubbock
	79407
	Lubbock

Client's Age at Referral: 66
DOB: 01-25-1953
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? Yes
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? Rent

Caretaker /Other Contact  Name: JoAnn Layland
Caretaker/Other Contact Phone: (806) 473-5616

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Front of house

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
Currently has a mobile home with 3-4 steps, light weight hand rail.  
The steps lead to a grass area, just to the south there is a walk way and 
covered parking area, approximately 20-30 feet from the front door.

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.
Ms. Prince is ambulatory but must use a walker do due balance issues.  
She is also legally blind and cannot see steps leading up or down the landing 
from the mobile home threshold and has a risk for fall.  

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


Referring Social Worker Full Name: Steve Lehmann
Name of Referring Agency: Texas Workforce Solutions
Referring Social Worker's Phone: (806) 765-5038
Referring Social Worker's Email: steve.lehmann@twc.state.tx.us