Your form "Client Referrals " has received the following response: 
Submitted on: 05/22/2019 11:32:43 PM
Completion time: 9 min. 32 sec.

Client Name and Address		Sylvia Vela
				(806) 572-3579
				Client Email
				605 E Lee St
				TX
				Floydada
				79235
				Floyd

Client's Age at Referral 64
DOB 10-15-1954
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? Yes
Did this person serve in the military? No

Client Financial Information
Is there a financial need, based on your agency's guidelines? Yes
Does the Client Own or Rent their home? Own

Caretaker/Other Contact Information
Rodrigo Vela 	(806) 685-3255

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
3 concrete steps 

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.
The member has history of falls when not using rolling walker. 
member has to have two people to help her leave the home. 

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

Referring Social Worker Information
Jennifer Whitfield RN ext1061081784
Amerigroup
(806) 748-4880
jennifer.whitfield@amerigroup.com