Your form "Client Referrals " has received the following response: 
Submitted on: 01/23/2019 10:03:14 AM
Completion time: 12 min. 18 sec.

Client Name and Address
				Belia Briseno
				(806) 388-4859
				Client Email
				331 E. Cleveland St. 
				Hale Center
				TX
				79041
				Hale

Client's Age at Referral: 67
DOB: 07-25-1951
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? Yes

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
Caretaker/Other Contact Phone

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

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
a walk path in front of the home and it is high. There are no rails for her to hold onto.

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.
Manual wheelchair and use walkers.

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

Referring Social Worker Information
Referring Social Worker Full Name:  Nicole Buchanan
Name of Referring Agency: United Healthcare
Referring Social Worker's Phone: (443) 492-5306
Referring Social Worker's Email: Nicole.Buchanan@optum.com