Your form "Client Referrals " has received the following response: 
Submitted on: 03/12/2020 03:36:36 PM
Completion time: 10 min. 5 sec.

Client Name and Address
				Jana Velasquez
				(806) 470-9616
				R. 
				1202 S. Walnut #26
				Idalou
				TX
				79329
				Lubbock

Client's Age at Referral: 43
DOB: 02-15-1977
Client's Gender: Female
Client's Ethnicity: Caucasian

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
Latayne Franklin
806 470-9616

Where is the ramp needed? (Be specific: front of house, side door, etc...)
front of the house at steps

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...) 
home has deck with 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.
Care recipient's health is declining making it difficult for her to get down steps for medical appointments. 
Mrs. Joyce's diagnosis is dementia, macular degeneration, blindness, uses walker and hypertension.

Is there an existing dangerous ramp at the client's home? R. 
Can the client provide 5 to 7 adult volunteers to help build the ramp? R. 


Referring Social Worker Information
Lisa Gonzales
Area Agency on Aging
806-687-0940
lgonzales@spag.org