The Texas Ramp Project does not accept direct referrals from our clients. All referrals must be made by third party health care agencies. The information will be sent to our region coordinator or designee and will be treated as confidential.
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Type of Request
New Ramp
Repair Ramp
Client Name and Address
Client First Name
Client Last Name
Client Home Phone
Client Email
Email Recipient
County Name
If a Client County is not listed, TRP is not actively building in this location. See "Where We Build" on our website for more detail.
SalesforceID
Client Address where ramp is to be built (No P.O. Box)
Client City
Client State
Client Postal Code
Additional Client Information
Client's Age at Referral
DOB (MM-DD-YYYY)
Client's Gender
Please select...
Male
Female
Client's Ethnicity
Please select...
Other
African American
Asian
Caucasian
Hispanic
Is this a hospice patient?
No
Yes
Is this a dialysis patient?
No
Yes
Is this a handicapped person living alone?
No
Yes
Did this person serve in the military?
No
Yes
Client Financial Information
Is there a financial need, based on the referring agency's guidelines
?
No
Yes
Does the Client Own or Rent their home?
Own
Rent
Caretaker/Other Contact Information
Family Member/Other Contact Name
Family Member/other Contact Phone
Ramp Information
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 there an existing dangerous ramp at the client's home?
Yes
No
Can the client /family provide any volunteers to help build the ramp?
Yes
No
Referring Social Worker Information
Referring Social Worker/Doctor/VA Full Name
Name of Referring Agency
Referring Social Worker/Doctor/VA Phone
Referring Social Worker/Doctor/VA Email
For help with issues on this form or completing this form, please email Nancy DeLuca at
NDeluca@texasramps.org
or call 214/558-0339