REV-IRM-77

Code
REV-IRM-77
Mercy ID
V-02023-01
Encounter Date
09/09/2005
Last
Redilla
First
Irma
DOB
05/15/1978
County
Dekalb
Street
2913 Shallowford
City
Chamblee
State
GA
Zip
30341-
Home
(000) 000-0000
Cell
(770) 895-1601
Family Status
Single parent w/children
COB
Mexico
Gender
Female
Housing
Not Homeless
Education Level
Preschool

Spouse Information

Last
Martinez
First
Victor
DOB
11/08/1972
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
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
Ana Patricia Martinez 08/26/1996 Mother GA/USA
Blanca Martinez 10/17/2001 Grandparents Mexico-Maternos
Jose Martinez 05/01/1994 Mother GA/USA
Kely Martinez 11/12/2002 Grandparents Mexico-Maternos
Luis Martinez 05/04/1993 Mother GA/USA
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