{"id":228,"date":"2016-04-28T21:50:38","date_gmt":"2016-04-28T21:50:38","guid":{"rendered":"https:\/\/www.palomar.edu\/drc\/?page_id=228"},"modified":"2016-04-28T21:50:38","modified_gmt":"2016-04-28T21:50:38","slug":"learning-disability-assessment-self-referral-form","status":"publish","type":"page","link":"https:\/\/www.palomar.edu\/drc\/drc-forms\/learning-disability-assessment-self-referral-form\/","title":{"rendered":"Learning Disability Assessment Self Referral Form"},"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 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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_7' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/drc\/wp-json\/wp\/v2\/pages\/228' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_7_24\" 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' >Your Name:<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_7_24'>\n                            \n                            <span id='input_7_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_7_24_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_7_24_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third 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_7_1'>Student ID Number:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_7_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third 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_7_8'>Date of Birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_7_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_4\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third 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_7_4'>Phone Number:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_7_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_6\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Palomar Student Email:<\/label><div class='gfield_description' id='gfield_description_7_6'>The Learning Disability Specialist will be using your Palomar student email address to contact you. Be sure to check your student email frequently.<\/div><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_7_6_container'>\n                                <span id='input_7_6_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6' id='input_7_6' value=''   placeholder='@student.palomar.edu'  aria-invalid=\"false\" aria-describedby=\"gfield_description_7_6\" \/>\n                                    <label for='input_7_6' class='gform-field-label gform-field-label--type-sub '>Enter Palomar Student Email ONLY<\/label>\n                                <\/span>\n                                <span id='input_7_6_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6_2' id='input_7_6_2' value=''   placeholder='@student.palomar.edu'  aria-invalid=\"false\" aria-describedby=\"gfield_description_7_6\" \/>\n                                    <label for='input_7_6_2' class='gform-field-label gform-field-label--type-sub '>Confirm Palomar Student Email ONLY<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_7_7\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Address:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_7_7_1' value=''    aria-required='false'    \/>\n                                        <label for='input_7_7_1' id='input_7_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_7_7_3' value=''    aria-required='false'    \/>\n                                    <label for='input_7_7_3' id='input_7_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_7_7_4' value=''      aria-required='false'    \/>\n                                        <label for='input_7_7_4' id='input_7_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_7_7_5' value=''    aria-required='false'    \/>\n                                    <label for='input_7_7_5' id='input_7_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_7_7_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_10'>Who Referred you for Possible Learning Disability Assessment?:<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_7_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_11\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_11'>What is your Educational Goal?:<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_7_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_12'>How Many Semesters have you Attended Palomar?:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_7_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you on Academic Probation?:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_13'>\n\t\t\t<li class='gchoice gchoice_7_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_7_13_0'    \/>\n\t\t\t\t<label for='choice_7_13_0' id='label_7_13_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_7_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_7_13_1'    \/>\n\t\t\t\t<label for='choice_7_13_1' id='label_7_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Prior to Attending Palomar College did you Receive Learning Disability Services or Assessment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_14'>\n\t\t\t<li class='gchoice gchoice_7_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_7_14_0'    \/>\n\t\t\t\t<label for='choice_7_14_0' id='label_7_14_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_7_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_7_14_1'    \/>\n\t\t\t\t<label for='choice_7_14_1' id='label_7_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_15'>Where and When?:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_7_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is Previous Learning Disability Verification Available?:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_17'>\n\t\t\t<li class='gchoice gchoice_7_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_7_17_0'    \/>\n\t\t\t\t<label for='choice_7_17_0' id='label_7_17_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_7_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_7_17_1'    \/>\n\t\t\t\t<label for='choice_7_17_1' id='label_7_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Has the Previous Learning Disability Verification Been Given to the DRC?:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_18'>\n\t\t\t<li class='gchoice gchoice_7_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_7_18_0'    \/>\n\t\t\t\t<label for='choice_7_18_0' id='label_7_18_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_7_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_7_18_1'    \/>\n\t\t\t\t<label for='choice_7_18_1' id='label_7_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is Another Disability Verified and Documented with the DRC?:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_19'>\n\t\t\t<li class='gchoice gchoice_7_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_7_19_0'    \/>\n\t\t\t\t<label for='choice_7_19_0' id='label_7_19_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_7_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_7_19_1'    \/>\n\t\t\t\t<label for='choice_7_19_1' id='label_7_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_20\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_20'>Why do you want to be evaluated for a learning disability?:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_7_20' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_7' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_7' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_7' id='gform_theme_7' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_7' 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data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"134\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 7, 'https:\/\/www.palomar.edu\/drc\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_7').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_7');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_7').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! 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