GOM-MAI-77

Code
GOM-MAI-77
Mercy ID
V-03157-01
Encounter Date
09/08/2009
Last
Gomez
First
Maria del carmen
DOB
07/15/1977
County
Douglass
Street
3726 Cindy Dr.
City
Douglasvillle
State
GA
Zip
30135-
Cell
(786) 346-1982
Family Status
Single adult
COB
Guatemala
Gender
Female
Housing
Doubling Up

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
Stephanie Bolaj 08/07/2002 Mother GA/USA

Former Spouse 1 Information

Last
Bolaj
First
Jaime
DOB
11/26/1978
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-Juana