Your form "Client Referrals " has received the following response: 
Submitted on: 02/08/2019 10:09:19 AM
Completion time: 32 min. 28 sec.

Client Name and Address
				Irema Villarreal
				(806) 928-8975
				Client Email: R. 
				611 28th St
				Lubbock
				TX
				79404
				Lubbock

Client's Age at Referral: 64
DOB: 12-31-1954
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? No
Did this person serve in the military? No

Is there a financial need, based on your agency's guidelines? No
Does the Client Own or Rent their home? Own

Caretaker /Other Contact  Name: Francesca Torres (daughter)
Caretaker/Other Contact Phone: (806) 448-1120

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

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.
limited physical mobility requiring a wheelchair for long distances and a walker for short distances.
Chronic Kidney Disease, Stage 3
Cirrhosis, Diabetes
frequent falls

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

Referring Social Worker Full Name: Courtney Walraven, LCSW
Name of Referring Agency: Covenant Medical Center
Referring Social Worker's Phone: (806) 725-3492
Referring Social Worker's Email: Courtney.Walraven@stjoe.org