GAY-DIA-78

Code
GAY-DIA-78
Mercy ID
V-03105-01
Encounter Date
06/29/2009
Last
Gaytan
First
Diana
DOB
11/24/1978
County
Forsyth
Street
415 Cambridge Rd. Apt. 340
City
Cumming
State
GA
Zip
30040-
Cell
(678) 349-6952
Family Status
Single parent w/children
COB
Mexico
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
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
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
Fatima Domingues 04/22/1997 Grandfather Mexico-Materno
Joana F. Dominguez 12/22/1994 Grandfather Mexico-Materno

Former Spouse 1 Information

Last
Parra
First
Alfredo
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
J. Perez
Data Entry
J. Manzo
Referred By
Amiga-Ana Lilia