Surpass Intake Lead Form

Client's Full Name

First NameLast Name
Client's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Parent/Guardian's Full Name

First NameLast Name
Mobile Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Case Manager's Full Name

First NameLast Name
Case Manager's Phone Number
Format: (000) 000-0000.
Case Manager's Email Address
example@example.com
Is the client located in Kentucky?
Positive Behavior Support Services are offered through Kentucky Medicaid Waivers (MPW, SCL, ABI) only. Which waiver program is the client applying through?
Nearest Clinic Location
Therapy Timeslot Preference:
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Participants must be located in Kentucky, qualify for the MPW, SCL, or ABI waivers, and meet Medicaid financial requirements to be eligible for Positive Behavior Support Services. If you are not located in Kentucky, but interested in ABA therapy services, please visit our Intake Form HERE. If you have additional questions, please email our intake team at intake@surpassbh.com and they will be happy to assist you.
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