HER-NOR-75

Code
HER-NOR-75
Mercy ID
V-01455-01
Encounter Date
01/05/2004
Last
Herrera
First
Norma
DOB
04/25/1975
County
Fulton
Street
5675 Roswell Rd.
City
Sandy spring
State
GA
Zip
30342-
Home
(678) 705-1763
Cell
(404) 484-0826
Family Status
Single parent w/children
COB
Mexico
Gender
Female
Housing
Single Family
Education Level
Grade school

Spouse Information

Last
N/A
First
N/A
DOB
N/A
Address
N/A
Telephone
N/A
COB
N/A
Home Owner
No
Driver
No
Home Owner
No
SOLO
No
Court Mandated
No
Program Completed
No
DFCS Mandated
No
Alcohol & Drug
No
Partner Referred to Tepestri
No
Recidivism/Court
No
New Incident
No
Promesa de Confidencialidad
No
Consentimiento De Participar
No

Petitioner

TPO
No
Stay Away Condition
No
Mutual
No

Defendant

TPO
No
Stay Away Condition
No
Mutual
No
Driver
YES
As A Child
No
Relative
No
Stranger
No
As An Adult
No
Partner
No
Relative
No
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Brayan Gutierrez 03/30/2005 Mother GA/USA
Cesar Ivan Rebollar 03/10/1996 Grandmother Mexico
Diego Gutierrez 06/09/1999 Mother Mexico
Edgar Alan Rebollar 07/25/1992 Mother GA/USA
Edwin Gutierrez 12/01/2003 Mother GA/USA

Former Spouse 1 Information

Last
Gutierrez
First
Margarito
DOB
06/10/1954
Telephone
N/A
COB
Mexico
Home Owner
No
NOTES

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
J. Manzo
Data Entry
K. Aleman
Referred By
x3737 Damaryz