BravEE Behavior – Service Intake Form

Welcome! Please fill out this form to help us better understand your needs and determine how we can support you. All information is confidential and protected under HIPAA.

Dr Regina Johnson is available for Speaking Engagement .
Just sent her an email at:

Contact Information
Client Information
Scheduling Preferences
Document Upload (Optional)
Consent & HIPAA Acknowledgment
Contact Information
Client Information
Behavioral & Developmental Background
Scheduling Preferences
Insurance & Payment Information
Document Upload (Optional)
Consent & HIPAA Acknowledgment