{"id":10613,"date":"2022-07-11T16:44:31","date_gmt":"2022-07-11T21:44:31","guid":{"rendered":"https:\/\/www.deltastate.edu\/student-affairs\/?page_id=10613"},"modified":"2026-04-08T12:02:20","modified_gmt":"2026-04-08T17:02:20","slug":"outreach-request-form","status":"publish","type":"page","link":"https:\/\/www.deltastate.edu\/students\/health-counseling-services\/outreach-request-form\/","title":{"rendered":"Health and Counseling Services Outreach Request Form"},"content":{"rendered":"[vc_row type=&#8221;in_container&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_spacing=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;]<style type=\"text\/css\">#nectar-slider-instance-1, #nectar-slider-instance-1 .swiper-container { min-height: 250px; } #nectar-slider-instance-1, #nectar-slider-instance-1 .swiper-container { height: calc( 420 * 100vw \/ 1600 ); } <\/style><div data-midnight=\"nectar-slider\" class=\"parallax_slider_outer \"><div  data-transition=\"slide\" data-overall_style=\"classic\" data-flexible-height=\"true\" data-animate-in-effect=\"none\" data-fullscreen=\"false\" data-button-sizing=\"regular\" data-button-styling=\"btn_with_count\" data-autorotate=\"\" data-parallax=\"true\" data-parallax-disable-mobile=\"\" data-caption-trans=\"fade_in_from_bottom\" data-parallax-style=\"bg_only\" data-bg-animation=\"none\" data-full-width=\"true\" class=\"nectar-slider-wrap \" id=\"nectar-slider-instance-1\"><div class=\"swiper-container\"  data-tho=\"auto\" data-tco=\"auto\" data-pho=\"auto\" data-pco=\"auto\" data-loop=\"false\" data-height=\"420\" data-min-height=\"250\" data-arrows=\"false\" data-bullets=\"false\" data-bullet_style=\"see_through\" data-bullet_position=\"bottom\" data-desktop-swipe=\"false\" data-settings=\"\"> <div class=\"swiper-wrapper\"><div class=\"swiper-slide\" data-desktop-content-width=\"auto\" data-tablet-content-width=\"auto\" data-bg-alignment=\"center\" data-color-scheme=\"light\" data-x-pos=\"left\" data-y-pos=\"bottom\" ><div class=\"slide-bg-wrap\"><div class=\"image-bg\" style=\"background-image: url(https:\/\/www.deltastate.edu\/students\/wp-content\/uploads\/sites\/34\/2021\/05\/Student-Health-Services-19-e1620658199571.jpg);\"> &nbsp; <\/div><div class=\"slide-bg-overlay\" style=\"background-color: #0a0a0a;\"> &nbsp; <\/div><\/div><div class=\"container\">\r\n\t\t\t\t\t\t<div class=\"content\"><h1>Health and Counseling Services Outreach Request Form<\/h1><\/div>\r\n\t\t\t\t\t\t\t\t<\/div><!--\/container--><div class=\"video-texture \"> <span class=\"ie-fix\"><\/span> <\/div><\/div> <!--\/swiper-slide--><\/div><div class=\"nectar-slider-loading \"> <span class=\"loading-icon none\">   <\/span> <\/div> <\/div> \r\n\t\t\t\t\t\r\n\t\t\t\t\t<\/div><\/div>[\/vc_column][\/vc_row][vc_row type=&#8221;in_container&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_spacing=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]You may submit the following form to the Office of Health and Counseling Services for an outreach request. Please submit your request at least <strong>10 business days<\/strong> before scheduled event.<\/p>\n<p>Outreach requests are available to all students, faculty, and staff. All requests will be screened by the outreach coordinator and you will be contacted by outreach staff regarding the request. Approval of requests are contingent upon scheduling, availability of staff, and type of request submitted.[\/vc_column_text][divider line_type=&#8221;No Line&#8221; custom_height=&#8221;25&#8243;]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_56' ><div id='gf_56' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_56' id='gform_56'  action='\/students\/wp-json\/wp\/v2\/pages\/10613#gf_56' data-formid='56' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_56' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_56_1\" class=\"gfield gfield--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_56_1'>Organization Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_56_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_56_3\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Person&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_56_3'>\n                            \n                            <span id='input_56_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_56_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_56_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_56_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_56_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_56_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_56_4\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Person&#039;s DSU Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_56_4_container'>\n                                <span id='input_56_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4' id='input_56_4' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_56_4' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_56_4_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4_2' id='input_56_4_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_56_4_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><\/fieldset><div id=\"field_56_5\" class=\"gfield gfield--type-phone gfield--width-full 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_56_5'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_56_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_56_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Contact Person&#039;s Affiliation with Delta State University<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_56_6'>\n\t\t\t<div class='gchoice gchoice_56_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Student'  id='choice_56_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_6_0' id='label_56_6_0' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_56_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Staff'  id='choice_56_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_6_1' id='label_56_6_1' class='gform-field-label gform-field-label--type-inline'>Staff<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_56_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Faculty'  id='choice_56_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_6_2' id='label_56_6_2' class='gform-field-label gform-field-label--type-inline'>Faculty<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_56_6_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Other'  id='choice_56_6_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_6_3' id='label_56_6_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_56_7\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Event<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_56_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_56_7_1_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_56_7_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_56_7_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_56_7_2_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_56_7_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_56_7_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_56_7_3_container'>\n                                            <input type='number' maxlength='4' name='input_7[]' id='input_56_7_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_56_7_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_56_8\" class=\"gfield gfield--type-time gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Event Start Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_56_8'>\n                            <input type='number' maxlength='2' name='input_8[]' id='input_56_8_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_56_8_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_8[]' id='input_56_8_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_56_8_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_8[]' id='input_56_8_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_56_8_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_56_9\" class=\"gfield gfield--type-time gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Event End Time<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_56_9'>\n                            <input type='number' maxlength='2' name='input_9[]' id='input_56_9_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_56_9_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_9[]' id='input_56_9_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_56_9_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_9[]' id='input_56_9_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_56_9_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_56_10\" class=\"gfield gfield--type-text gfield--width-half 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_56_10'>Event Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_56_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_56_11\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_56_11'>Estimated # of People Attending Event<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_56_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_56_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Audience (Select all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_56_12'><div class='gchoice gchoice_56_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Students'  id='choice_56_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_12_1' id='label_56_12_1' class='gform-field-label gform-field-label--type-inline'>Students<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_56_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Staff'  id='choice_56_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_12_2' id='label_56_12_2' class='gform-field-label gform-field-label--type-inline'>Staff<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_56_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Faculty'  id='choice_56_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_12_3' id='label_56_12_3' class='gform-field-label gform-field-label--type-inline'>Faculty<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_56_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Other (please be as specific as possible)'  id='choice_56_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_56_12_4' id='label_56_12_4' class='gform-field-label gform-field-label--type-inline'>Other (please be as specific as possible)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_56_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type of Outreach Request:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_56_13'>\n\t\t\t<div class='gchoice gchoice_56_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Workshop\/Presentation\/Training'  id='choice_56_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_13_0' id='label_56_13_0' class='gform-field-label gform-field-label--type-inline'>Workshop\/Presentation\/Training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_56_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Tabling'  id='choice_56_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_13_1' id='label_56_13_1' class='gform-field-label gform-field-label--type-inline'>Tabling<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_56_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Presence of a Counselor at Your Event'  id='choice_56_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_13_2' id='label_56_13_2' class='gform-field-label gform-field-label--type-inline'>Presence of a Counselor at Your Event<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_56_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Media\/Interview Request'  id='choice_56_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_56_13_3' id='label_56_13_3' class='gform-field-label gform-field-label--type-inline'>Media\/Interview Request<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_56_14\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_56_14'>Specific Areas You Would Like Addressed (e.g. grief, trauma, recognizing signs of depression and anxiety, stress management, mindfulness exercises)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_56_14' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_56_15\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_56_15'>Please add any additional information below:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_56_15' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_56_16\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_56_16'>X\/Twitter<\/label><div class='ginput_container'><input name='input_16' id='input_56_16' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_56_16'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_56' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=56&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=5e23cd7422ecdd84976518f79e816abf' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_56' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_56' id='gform_theme_56' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_56' id='gform_style_settings_56' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_56' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='56' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_56' value='WyJ7XCI2XCI6W1wiY2I0ZmFjZTMwYmZhMjFiODAwYmJkMjBlNzcyMDAyOWZcIixcImZmMmUwYjE5YTVhYTQyZjZjN2UyMWE3ODRlNDU2ZjQ3XCIsXCIyOThmZGZmZWNlMzJhZjAxNTJkMWZmYzFmYjJkZTA5NFwiLFwiZmU0YjZjYWEwYzMwZjEzOWQzM2MzNDI5NjYzZWIzZWNcIl0sXCIxM1wiOltcIjRhMDU1Nzg5MzJjZDc2NzYxNGEwM2EwZDlkZjNhNmU4XCIsXCI4MDM3OWE1YWVmN2VjMDI4NDUxODcwYjk3NDRmZWI0M1wiLFwiMjI4NDk3MDA2YWYzNWQ2NDVhMWMyNWNhZjMwNGI2ZGJcIixcIjg2MGYzOTUxZGQ4Mzc5ZWE1OTY3MTQxZjk5NGIzNjEwXCJdfSIsIjEyNjlkNTdlNjhlMGI3MGVlZTg4NDM5OTc2NGE1ZThmIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_56' id='gform_target_page_number_56' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_56' id='gform_source_page_number_56' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_56' id='gform_ajax_frame_56' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 56, 'https:\/\/www.deltastate.edu\/students\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_56').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_56');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_56').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_56').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_56').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_56').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_56').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_56').val();gformInitSpinner( 56, 'https:\/\/www.deltastate.edu\/students\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [56, current_page]);window['gf_submitting_56'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_56').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_56').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [56]);window['gf_submitting_56'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_56').text());}else{jQuery('#gform_56').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"56\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_56\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_56\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_56\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 56, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n[\/vc_column][\/vc_row]\n","protected":false},"excerpt":{"rendered":"<p>[vc_row type=&#8221;in_container&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_spacing=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221;&#8230;<\/p>\n","protected":false},"author":530,"featured_media":0,"parent":10117,"menu_order":99,"comment_status":"closed","ping_status":"closed","template":"page-left-sidebar.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-10613","page","type-page","status-publish"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/pages\/10613","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/users\/530"}],"replies":[{"embeddable":true,"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/comments?post=10613"}],"version-history":[{"count":4,"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/pages\/10613\/revisions"}],"predecessor-version":[{"id":16634,"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/pages\/10613\/revisions\/16634"}],"up":[{"embeddable":true,"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/pages\/10117"}],"wp:attachment":[{"href":"https:\/\/www.deltastate.edu\/students\/wp-json\/wp\/v2\/media?parent=10613"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}