Request a BurkePsych Secure Mail Account

You indicated on the previous page that you are one of Dr. Burke's clients' family members or you have some other close, personal relationship with a client (such as caregiver, life partner, dependent, etc.). In order to protect both my client's and your own privacy, I need to first confirm that you are who you say that you are and also that you have a legal right to information about the client. If you are uncomfortable including information in this form, simply complete what you wish and I will contact you and the client to confirm your request.

Please complete the form below to request an account.

Your Name:    Your Relationship to Client:  

Client's Name:    Client's Date of Birth:

Preferred Phone:  

Your E-Mail:   Confirm your E-Mail:

Last 4-digits of your SSN:  Last 4-digits of client's SSN:  

Type of service I provide/provided to the client: (not selected) online counseling individual counseling/therapy couples' counseling testing/evaluation other
 
Are you the client's parent or legal guardian? Yes No
     If not, has the client given me written consent to communicate with you? n/a Yes No

Explain your reason for requesting an account: 

Security Question:
          (not selected) What is your favorite food? What was the name of your school in first grade? What is the name of your pet? In what county were you born? What is a secret word of your choosing? What is the first name of your paternal grandfather? What is your mother's maiden name?
  Answer to security question:

(Please click only once - encryption may take a few moments)

For best encryption, be sure you have the Java Runtime Environment installed on your computer.

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