MED-BLA-74

Code
MED-BLA-74
Mercy ID
V-02820-01
Encounter Date
06/16/2008
Last
Medrano
First
Blanca
DOB
04/27/1974
County
Gwinnett
Street
171 Paper Mill Road
City
Lawrenceville
State
GA
Zip
30045-
Home
(770) 995-5814
Cell
(678) 517-4041
Family Status
Single parent w/children
COB
El Salvador
Gender
Female
Housing
Single Family
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
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
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
Blanca Molina 12/15/1995 Mother GA/USA

Former Spouse 1 Information

Last
Estrada
First
Erik
DOB
N/A
Telephone
N/A
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
G. Landeros
Data Entry
J. Manzo
Referred By
linea