DOM-GUA-55

Code
DOM-GUA-55
Mercy ID
V-01324-01
Encounter Date
08/22/2003
Last
Dominguez
First
Guadalupe
DOB
12/08/1955
County
Dekalb
Street
2515 Northeast Expressway Rd. #-D-4
City
Atlanta
State
GA
Zip
30345-
Home
(404) 634-5156
Cell
(678) 548-7252
Family Status
Two parent family w/children
COB
Mexico
Gender
Female
Housing
Not Homeless
Education Level
Grade school

Spouse Information

Last
Ortiz
First
Alejandro
DOB
05/03/1955
Address
N/A
Telephone
N/A
COB
Mexico
Home Owner
YES
Driver
No
Home Owner
YES
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
YES
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Alejandra Lluvia Ortiz 06/15/1991 Parents GA/USA
Alejandro Ortiz 12/10/1992 Parents GA/USA
Angelica Ortiz 04/25/1991 Parents GA/USA
Olivia Ortiz 08/05/1987 Parents GA/USA
Ricardo Ortiz 02/22/1985 Parents GA/USA
NOTES

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
G. Landeros
Data Entry
K. Aleman
Referred By
x3737 Damaryz