Your form "Client Referrals " has received the following response: 
Submitted on: 04/09/2019 03:14:57 PM
Completion time: 14 min. 2 sec.

Client Name and Address
				Laura Valdez
				(806) 454-0201
				Client Email R. 
				620 Avenue J 
				TX
				Ralls
				79357
				Crosby

Client's Age at Referral: 37
Client's DOB: 12-10-1981
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  Name: member sister Cristina 
Caretaker/Other Contact Phone: (806) 392.8128

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
The existing platform and steps are part concrete, part wood. The door is centered 
on both.  The wood section is so rotten that the member and their family avoid stepping 
on it. This is posing a danger to the member and her safety. 

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.
Member is intellectually disabled with morbid obesity, knee pain, back pain and 
SOB with any exertion. Member has chronic leg pain and has a difficult time lifting 
legs. Members gait is poor and unbalanced. 

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

Referring Social Worker Full Name:  Jennifer Whitfield RN
Name of Referring Agency: Amerigroup
Referring Social Worker's Phone: (806)748-4880
Referring Social Worker's Email: jennifer.whitfield@amerigroup.com