GOM-XIM-61

Code
GOM-XIM-61
Mercy ID
V-01987-01
Encounter Date
08/15/2005
Last
Gomez
First
Ximena
DOB
08/11/1961
County
Fulton
Street
325 Hemincway Lane
City
Roswell
State
GA
Zip
30075-
Home
(678) 768-5147
Family Status
Adult coupie-no children
COB
Mexico
Gender
Female
Housing
Not Homeless
Education Level
some high school

Spouse Information

Last
N/A
First
N/A
DOB
N/A
Address
N/A
Telephone
N/A
COB
Mexico
Home Owner
No
Driver
No
Home Owner
YES
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
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
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