MAR-ALI-77

Code
MAR-ALI-77
Mercy ID
V-03158-01
Encounter Date
09/08/2009
Last
Martinez
First
Alicia
DOB
03/19/1977
County
Gwinnett
Street
908 Crossing Park Way
City
Lilburn
State
GA
Zip
30047-
Cell
(770) 875-9202
Family Status
Two parent family w/children
COB
Mexico
Gender
Female
Housing
Single Family
Education Level
some high school

Spouse Information

Last
Lopez
First
Jose
DOB
03/19/1986
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

Former Spouse 1 Information

Last
Sanchez
First
Israel
DOB
09/27/1976
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
Linea-enfermera de clinica le dio #