{"id":1154,"date":"2020-04-03T22:49:22","date_gmt":"2020-04-03T22:49:22","guid":{"rendered":"https:\/\/www.palomar.edu\/drc\/?page_id=1154"},"modified":"2026-08-20T23:03:14","modified_gmt":"2026-08-21T06:03:14","slug":"drc-contact-form","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/drc\/drc-contact-form\/","title":{"rendered":"Contact the DRC"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_14' ><form method='post' enctype='multipart\/form-data'  id='gform_14'  action='\/drc\/wp-json\/wp\/v2\/pages\/1154' data-formid='14' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_14_1\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><H3>Appointment and General Information Request<\/H3>\n<P>Please respond to the questions on this page and someone will contact you as soon as possible.<br \/>If you have any difficulty with this form, please call the DRC at 760-744-1150, ext. 2375.<\/P>(NOTE: This form is not an application to the DRC program, the application can be found at: <a href=\"https:\/\/www.palomar.edu\/drc\/getting-started-applying-to-drc\/\">Apply to the DRC)<\/a><\/p><\/li><li id=\"field_14_14\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><P><STRONG>NOTE:<\/STRONG> Remote DRC Drop-In Counseling is held Monday through Thursday, 10:00AM-2:00PM and Friday from 11AM-12PM<\/P>\n<P>If you are interested in a DRC Counselor calling you for a 10-15 minute phone or Zoom drop-in counseling session, email <A HREF=\"mailto:drc@palomar.edu\">drc@palomar.edu<\/A> or call 760-744-1150, ext. 2375 during this timeframe.<\/P><\/li><li id=\"field_14_4\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_14_4'>\n                            \n                            <span id='input_14_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' id='input_14_4_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_14_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.6' id='input_14_4_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_14_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_14_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_6'><span class='gform-field-label__text'>Palomar Student ID<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_14_6' type='text' value='' class='medium'    placeholder='999999999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"999999999\"\/><\/div><\/li><li id=\"field_14_8\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Email Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_14_8_container'>\n                                <span id='input_14_8_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_8' id='input_14_8' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_14_8' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_14_8_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_8_2' id='input_14_8_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_14_8_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_14_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_9'><span class='gform-field-label__text'>Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_14_9' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_14_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Is the phone number you provided one of the following:<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_14_21'><li class='gchoice gchoice_14_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Cell Phone'  id='choice_14_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_21_1' id='label_14_21_1' class='gform-field-label gform-field-label--type-inline'>Cell Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Home Phone'  id='choice_14_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_21_2' id='label_14_21_2' class='gform-field-label gform-field-label--type-inline'>Home Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Video Phone'  id='choice_14_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_21_3' id='label_14_21_3' class='gform-field-label gform-field-label--type-inline'>Video Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='No Phone Number'  id='choice_14_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_21_4' id='label_14_21_4' class='gform-field-label gform-field-label--type-inline'>No Phone Number<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you a current DRC student?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_14_20'>\n\t\t\t<li class='gchoice gchoice_14_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_14_20_0'    \/>\n\t\t\t\t<label for='choice_14_20_0' id='label_14_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_14_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='No'  id='choice_14_20_1'    \/>\n\t\t\t\t<label for='choice_14_20_1' id='label_14_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>How can we help you? (check all that apply)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_14_10'><li class='gchoice gchoice_14_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Requesting a counseling appointment with a DRC Counselor'  id='choice_14_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_10_1' id='label_14_10_1' class='gform-field-label gform-field-label--type-inline'>Requesting a counseling appointment with a DRC Counselor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Requesting updated accommodation\/Accommodation Letters'  id='choice_14_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_10_2' id='label_14_10_2' class='gform-field-label gform-field-label--type-inline'>Requesting updated accommodation\/Accommodation Letters<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='I have a question involving test proctoring'  id='choice_14_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_10_3' id='label_14_10_3' class='gform-field-label gform-field-label--type-inline'>I have a question involving test proctoring<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Alternate media (electronic textbooks or assistive technology)'  id='choice_14_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_10_4' id='label_14_10_4' class='gform-field-label gform-field-label--type-inline'>Alternate media (electronic textbooks or assistive technology)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_10_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.5' type='checkbox'  value='DHH Services (ASL interpreting, captioning, assistive listening device, etc.)'  id='choice_14_10_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_10_5' id='label_14_10_5' class='gform-field-label gform-field-label--type-inline'>DHH Services (ASL interpreting, captioning, assistive listening device, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_10_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.6' type='checkbox'  value='Other'  id='choice_14_10_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_10_6' id='label_14_10_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_14_11'><span class='gform-field-label__text'>Briefly describe your question or request:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_14_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_14_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your preferred method of communication:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_14_12'><li class='gchoice gchoice_14_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Email'  id='choice_14_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_12_1' id='label_14_12_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Phone'  id='choice_14_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_12_2' id='label_14_12_2' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_14_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Video Meeting (thru Zoom)'  id='choice_14_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_14_12_3' id='label_14_12_3' class='gform-field-label gform-field-label--type-inline'>Video Meeting (thru Zoom)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_14_16\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>FERPA Disclaimer:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description gfield_consent_description' id='gfield_consent_description_14_16'><div class='gfield_consent_description_text' tabindex='0'>Due to the abrupt transition to remote services as a result of the college response to the COVID-19 virus, DRC is seeking to maintain services for students through creative ways. In order to comply with Family Education Rights and Privacy Act (FERPA), a two question identification authentication will be required prior to releasing student academic information over the phone, or in the remote counseling environments. I grant permission for Palomar DRC to release my academic information during a remote counseling appointment conducted by phone, email or video (Zoom).<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_16.1' id='input_14_16_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_14_16\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_14_16_1' ><span class='gform-field-label__text'>Click to acknowledge that you have read and agree to the above paragraph.<\/span><\/label><input type='hidden' name='input_16.2' value='Click to acknowledge that you have read and agree to the above paragraph.' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='7' class='gform_hidden' \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_14' 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