BAZ-ROM-82

Code
BAZ-ROM-82
Mercy ID
V-02464-01
Encounter Date
04/11/2007
Last
Bazan
First
Romeli
DOB
11/21/1982
County
Fulton
Street
221 Creekfide Way
City
Roswell
State
GA
Zip
30076-
Cell
(404) 552-2549
Family Status
Single parent w/children
COB
USA
Gender
Female
Housing
Doubling Up
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
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
YES
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Johnny David Peña 09/20/2005 Mother GA/USA

Former Spouse 1 Information

Last
Peña
First
Johnny
DOB
12/23/1979
Telephone
N/A
COB
Mexico
Home Owner
YES
NOTES

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
G. Landeros
Data Entry
J. Manzo
Referred By
Linea-Juana