Client Referrals

Information in RED is required.

Client's name:
Address:
City:
State:
Zip code:
Client's phone:
Caretaker name or other contact:
Caretaker/contact phone(s):
Client's date of birth:	Clients 60+ year of age qualify for specific funding sources
Name of referring social worker:
Referring agency:
Referring social worker's phone(s):
Referring social worker's e-mail:
Where is the ramp needed? (Be specific: front of house, side door, etc...)
Provide a brief description of the obstacle(s) (e.g. a door threshold, a single step, a mobile home with three steps, etc...)
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.
Is this a hospice patient?
Is this a dialysis patient?
Is this a handicapped person living alone?
Is there a financial need, based on your agency's guidelines?
Did this person serve in the military?