Your form "Client Referrals " has received the following response: 
Submitted on: 03/13/2019 01:51:00 PM
Completion time: 7 min. 5 sec.

Client Name and Address
				Juanita Trevina
				(806) 300-1521
				Client Email
				809 14th
				TX
				Abernathy
				79311
				Hale

Client's Age at Referral: 73
DOB: 06-19-1945
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? 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? Rent

Caretaker/Other Contact Information
Julian Mirelez
(806) 317-3932

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...) 
2 steps and door threshold

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.
chairbound w/ manual wheelchair

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

Referring Social Worker Information
Referring Social Worker Full Name: Phyllis Suber-Raper
Name of Referring Agency: Dept of Health and Human Services
Referring Social Worker's Phone: 806-296-3145
Referring Social Worker's Email: phyllis.suber-raper@hhsc.state.tx.us