Your form "Client Referrals " has received the following response: 
Submitted on: 03/28/2019 06:11:29 PM
Completion time: 18 min. 41 sec.

Client Name and Address 	Timothy Santilian
				(432) 631-7598
				timothyjoesantilian@yahoo.com
				1810 Quin Drive
				TX
				Brownfield
				79316
				Terry

Client's Age at Referral: 34
DOB: 09-02-1984
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? 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 Information
Caretaker /Other Contact  Name: Gladys Ledezma
Caretaker/Other Contact Phone: (806) 831-2989

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Back of the house so he can have access to leave the house in case of a fire in the front 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...) 
This is a mobile home and has three steps and no hand rails for Providers. 

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.
Timothy is quadriplegic and depends on his powered wheelchair to take him where he needs to go. 
Timothy's prognosis is not expected to change. 

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

Referring Social Worker Full Name: Susana Garcia
Name of Referring Agency: West Texas Centers
Referring Social Worker's Phone: (806) 637-3206
Referring Social Worker's Email: susana.garcia@wtcmhmr.org