Request a BurkePsych Secure Mail Account

You indicated on the previous page that you are one of Dr. Burke's previous clients. To protect your privacy, I need to first confirm that you are who you say that you are. This prevents someone from creating an account in your name without your knowledge. If you are uncomfortable including information in this form, simply complete what you wish and I will contact you to confirm your request.

Please complete the form below to set up an account.

Your Name:   Date of Birth:

E-Mail:   Confirm your E-Mail:

Preferred Phone:   Last 4-digits of SSN:

Type of service I last provided to you: (not selected) online counseling individual counseling/therapy couples' counseling testing/evaluation other

Approximate dates you were a client:

How did you pay for your services?: : (not selected) insurance self-pay someone else paid Employer Assistance Program other

Tell me something only I would know about you:

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.

If you reached this page in error and are not a previous client, please click here.