PEÑ-ROS-77

Code
PEÑ-ROS-77
Mercy ID
V-02691-01
Encounter Date
01/16/2008
Last
Peña
First
Rosa
DOB
03/05/1977
County
Gwinnett
Street
2605 Avalon Circle
City
Lawrenceville
State
GA
Zip
30044-
Cell
(678) 612-2868
Family Status
Single parent w/children
COB
Dominican Rep
Gender
Female
Housing
Doubling Up
Education Level
High school graduate

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
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
No
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Alina Anyelis Betancez 07/11/1997 Mother GA/USA
Roselin Servin 05/22/2005 Mother GA/USA
Yoleski Servin 01/18/2006 Mother GA/USA

Former Spouse 1 Information

Last
Peña
First
Paul
DOB
N/A
Telephone
N/A
COB
USA
Home Owner
YES

Former Spouse 2 Information

Last
L?????????????????????????????
First
L?????????????????????????????
DOB
N/A
Telephone
N/A
COB
Mexico
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
J. Manzo
Referred By
linea-Juana