Your form "Client Referrals " has received the following response:
11/18/2018 7:30
Completion time: 5 min. 32 sec.

Client Name and Address
Client Rosie West
806-762-3894
juiwanor@yahoo.com
1714 East 28th Street
Lubbock
TX
79404
County: Lubbock

Client's Age at Referral: 79
DOB: 1/19/1942
Client's Gender: Female
Client's Ethnicity: African American

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
Caretaker /Other Contact  Name: Juiwanor Clarke
Caretaker/Other Contact Phone: 361-876-4080

Ramp Information
Where is the ramp needed? The ramp is needed in front of house

Description of obstacles(s): 
The door threshold is to high and there are three steep steps that are too high for the 
home owner to climb.

Details of mobility:
The pt has assisted walking.

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

Referring Social Worker Information
Referring Social Worker Full Name: Juiwanor Clarke
Name of Referring Agency: Advocate for Life
Referring Social Worker's Phone: 361-876-4080
Referring Social Worker's Email: juiwanor@yahoo.com