ROM-AMA-80

Code
ROM-AMA-80
Mercy ID
V-02558-01
Encounter Date
09/03/2007
Last
Roman
First
Amada
DOB
09/13/1980
County
Dekalb
Street
IWH
City
Veracruz
State
GA
Zip
99999-
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
N/A
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
YES
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
No
Relative
No
Stranger
No
As An Adult
No
Partner
No
Relative
No
Stranger
No

Children

NAME DOB LIVING WITH STATE/COUNTRY
Japziri Carmona 01/16/2003 Mother Mexico
Jovana Carmona 10/24/1996 Mother Mexico
Odalis Carmona 11/25/1999 Mother Mexico
Rosana Carmona 10/27/2001 Mother Mexico

Former Spouse 1 Information

Last
Carmona
First
Javier
DOB
04/30/1977
Telephone
N/A
COB
N/A
Home Owner
No
NOTES
011-52-122-9-905-9338

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