VER-SEL-63

Code
VER-SEL-63
Mercy ID
V-02479-02
Encounter Date
05/01/2007
Last
Vera
First
Selestino
DOB
05/19/1963
County
Fulton
Street
1149 Thomas Dr.
City
Roswell
State
GA
Zip
30075-
Home
(770) 518-8867
Cell
(404) 838-0979
Family Status
Single adult
COB
Mexico
Gender
Male
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
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
No
Consentimiento De Participar
No

Petitioner

TPO
No
Stay Away Condition
No
Mutual
No

Defendant

TPO
No
Stay Away Condition
No
Mutual
No
Driver
No
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
Jessica Vera N/A Mother GA/USA
Luis Antonio Vera N/A Mother GA/USA
Yadira Vera N/A Mother GA/USA

Former Spouse 1 Information

Last
Gallegos
First
Silvia
DOB
N/A
Telephone
(770) 896-4815
COB
N/A
Home Owner
No
NOTES

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
J. Manzo
Data Entry
J. Manzo
Referred By
Felipe