PER-ELI-74

Code
PER-ELI-74
Mercy ID
V-03179-01
Encounter Date
09/28/2009
Last
Perez
First
Elizabeth
DOB
05/07/1974
County
Hall
Street
999 Shelter
City
Gainsville
State
GA
Zip
30501-
Cell
(770) 536-5860
Family Status
Single parent w/children
COB
Mexico
Gender
Female
Housing
Shelter
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
YES
As A Child
YES
Relative
YES
Stranger
No
As An Adult
YES
Partner
No
Relative
No
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Andrea Perez 09/04/2000 Mother GA/USA
Daisy Perez 01/01/1999 Mother GA/USA
Erick Perez 08/13/2008 Mother GA/USA

Former Spouse 1 Information

Last
Perez
First
Fernando
DOB
05/30/1973
Telephone
N/A
COB
Mexico
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-Griselda