Your form "Client Referrals " has received the following response: 
Submitted on: 01/31/2019 10:39:59 AM
Completion time: 5 min. 18 sec.

Client Name and Address
	Janie Villareal
	(806) 729-1714
	Client Email 
	612 Irving
	Littlefield
	TX
	79339
	Lamb

Client's Age at Referral: 62
DOB: 10-13-1956
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

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
Caretaker/Other Contact Phone

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
In 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...)
has steps that are not stable. 

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.
CL is going to get surgery on her leg and struggling to walk. 

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

Referring Social Worker Full Name: Anna Zuniga
Name of Referring Agency: Adult Protective Services
Referring Social Worker's Phone: (806) 420-8092
Referring Social Worker's Email: anna.zuniga@dfps.state.tx.us