Your form "Client Referrals " has received the following response: 
Submitted on: 08/07/2019 08:02:24 AM
Completion time: 8 min. 22 sec.

Client Name and Address		Ricki Ward
				(806) 200-0281
				Client Email
				621 E 14th St
				TX
				Littlefield 
				79339
				Lamb

Client's Age at Referral: 44
DOB: 05-10-1975
Client's Gender: Male
Client's Ethnicity: Other

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? Own

Caretaker/Other Contact Information
Kayla Pickard 		(806) 264-1052

Where is the ramp needed? (Be specific: front of house, side door, etc...) 
Ramp to 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...) 
mbr living in a home and is requesting a ramp to be placed in front 

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.
Mbr is morbidly obese and uses a walker to ger around 

Is there an existing dangerous ramp at the client's home? R. 

Referring Social Worker  
Samantha Wilbanks
Amerigroup
(806) 748-4880
samantha.wilbanks@amerigroup.com