DOM-CAN-68

Code
DOM-CAN-68
Mercy ID
V-00327-01
Encounter Date
11/07/2000
Last
Dominguez
First
Candy
DOB
02/06/1968
County
Fulton
Street
303 Sewoin Rd. Apt. 7
City
Furburn
State
GA
Zip
30212-
Home
(770) 306-5185
Family Status
Two parent family w/children
COB
USA
Gender
Female
Housing
Not Homeless
Education Level
Some College

Spouse Information

Last
Dominguez
First
Rogelio
DOB
07/27/1967
Address
N/A
Telephone
N/A
COB
Mexico
Home Owner
No
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
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
Ma. Guadalupe Dominguez 07/07/1999 Parents GA/USA
NOTES
Signed consent form and promesa before the fire

Media Authoritation

NO DOY PERMISO
DOY PERMISO
No
Limitado Impresos
No
Limitado Educativo
No
Limitado CL
No
Intake
J. Perez
Data Entry
K. Aleman
Referred By
Evaluación