MAT-IME-72

Code
MAT-IME-72
Mercy ID
V-01643-01
Encounter Date
06/29/2004
Last
Mata
First
Imelda
DOB
06/29/1972
County
Gwinnett
Street
5615 Hammon Dr.
City
Norcross
State
GA
Zip
30071-
Home
(404) 643-2852
Family Status
Two parent family w/children
COB
Mexico
Gender
Female
Housing
Not Homeless
Education Level
Grade school

Spouse Information

Last
Ramos
First
Juan carlos
DOB
03/30/1982
Address
N/A
Telephone
N/A
COB
Mexico
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
YES
Consentimiento De Participar
YES

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
Adriana Lopez 05/19/1990 Father Mexico
Elizabeth Ramos 04/16/2004 Parents GA/USA
Karla Lopez 06/19/1996 Mother w/Stepfather GA/USA
NOTES

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
J. Perez
Data Entry
K. Aleman
Referred By
Rafael Miranda