MEN-MIR-72

Code
MEN-MIR-72
Mercy ID
V-01897-01
Encounter Date
04/19/2005
Last
Mena
First
Mirely
DOB
07/26/1972
County
Fulton
Street
3006 Delmar Lane NW # B-1
City
Atlanta
State
GA
Zip
30311-
Home
(404) 696-6733
Cell
(404) 822-4811
Family Status
Single parent w/children
COB
Honduras
Gender
Female
Housing
Doubling Up
Education Level
Grade school

Spouse Information

Last
Diaz
First
Lucio
DOB
03/02/1985
Address
N/A
Telephone
N/A
COB
Mexico
Home Owner
No
Driver
No
Home Owner
No
SOLO
No
Court Mandated
YES
Program Completed
YES
DFCS Mandated
No
Alcohol & Drug
No
Partner Referred to Tepestri
No
Recidivism/Court
No
New Incident
No
Promesa de Confidencialidad
YES
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
Degny Molina 11/01/2001 Mother w/Stepfather GA/USA
Johua Diaz 03/27/2007 Parents GA/USA
Samantha Molina 01/28/2000 Mother w/Stepfather GA/USA
Yolanda Molina 02/28/1990 Adulto/Casado GA/USA

Former Spouse 1 Information

Last
Molina
First
Degny
DOB
02/11/1975
Telephone
N/A
COB
Honduras
Home Owner
No
NOTES

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
G. Landeros
Data Entry
K. Aleman
Referred By