Formstack Submission for form Client Referrals at 02/07/14 12:28 PM 

 Client's Name: Silvestre Serna
       Address: 308 Uvalde
                Lubbock, TX 78415 
        County: Lubbock
Client's Phone: (806) 747-4840

Caretaker name or other contact: Ester Serna
Caretaker / contact phone: (512) 964-7064

Client's date of birth: 06/05/1934
Client's age at time of referral: 80
Client's gender: Male
Client's Ethnicity: Hispanic

Name of referring social worker: Ester Serna
Referring Agency: daughter
Referring social worker's phone: (512) 964-7064
Referring social worker's email: etiserna@yahoo.com

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 single 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.: Walker

Is this a hospice patient?: No
Is this a dialysis patient?: No
Is this a handicapped person living alone?: No
Is there a financial need, based on your agency's guidelines?: No
Did this person serve in the military?: No