MAR-LUZ-66

Code
MAR-LUZ-66
Mercy ID
V-00195-01
Encounter Date
04/28/2000
Last
Martinez
First
Luz elena
DOB
09/12/1966
County
Gwinnett
Street
5141 Highway 78 Lot 212
City
Stone mountain
State
GA
Zip
30087-
Cell
(770) 235-7495
Family Status
Single parent w/children
COB
Mexico
Gender
Female
Housing
Single Family
Education Level
Vocational/Technical

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
No
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Alejandro Martinez 03/31/1991 Mother GA/USA
Eric Martinez 09/17/1996 Mother GA/USA
Juan Carlos Martinez 10/20/1985 Adulto/Casado GA/USA

Former Spouse 1 Information

Last
Martinez
First
Juan carlos
DOB
03/04/1963
Telephone
N/A
COB
Mexico
Home Owner
No
NOTES
Luz was not included in the grant report of 10/02-3/03 because she has been reported as driver's license in 2000. Juana gave me this form 3/13/03

Media Authoritation

NO DOY PERMISO
DOY PERMISO
YES
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
J. Perez
Data Entry
K. Aleman
Referred By