Hours of Operation

Monday - Friday 8:00am - 9:00pm with the exception of Wednesday the clinic is open from 8:00am - 12:00pm, and 5:00pm - 9:00pm.

Saturday - 9:00am - 1:00pm

Patient Satisfaction Survey

Youth Mentoring Program

Mentee Referral

(For Use by School and Other Community Agency Staff)
Youth's Name:
Age: Grade:
School:
Requested by:
Position: Phone Number:
The child is being referred for assistance in the following areas (check all that apply):
Academic Issues Behavioral Issues Delinquency Vocational Training
Self-Esteem Study Habits Social Skills Peer Relationships
Family Issues Special Needs Attitude    
Other, specify:
Why do you feel this youth might benefit from a Mentor?


What particular interests, either in school or out, do you know of that the child has?


What strategies/learning models might be effective for a Mentor working with this youth?
On a scale of 1–10 (10 being highest) rate the student’s level of:
Academic performance
Social skills
Self-esteem
Family support
Communication skills
Attitude about school/education
Peer relations
With what specific subjects, if any, does the student need assistance?


Additional comments: