Inquiry Form

Thank you for reaching out! This is a secure inquiry form for services with Kimberly Galindo PLLC. Once we receive your form, we will reach out via email within two business days to discuss next steps.

First Name

Last Name

Nick Name or Preferred Name

Email address

Phone Number

Address

Street Address

Street Address Line 2

City

State

Zip Code

Date of Birth

Permission to Contact

Phone: I use phone calls only for pre-scheduled appointments or to follow up on late cancellations and no-shows. Email: Email is reserved for scheduling and administrative matters only (e.g., appointment coordination, paperwork, or billing questions). Please note that I do not provide clinical support or therapeutic services via phone or email. If you are experiencing a crisis, please contact emergency services or a crisis line in your area.

Who are you seeking services for?

Myself

Myself and another party (spouse, partner, family member)

My child (17 and younger)

My Child (18 and older)

Another adult family member

Other (please note)

For those seeking services on behalf of another party:

If the other party is a minor, we can only fully explore potential services with the minor's guardian(s).

If the other party is an adult (18 years or older), we cannot make arrangements or discuss details of potential services with anyone other than the prospective adult client. The prospective adult client must contact our office directly to initiate any processes or services.

We can discuss general processes and provide basic information about Aspen Haus with any party that would like more information

History of Professional Services & Care

Have you previously sought or received services from Kimberly Galindo?

Yes

Please list all current and previous MENTAL HEALTH PROVIDERS from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)

Please list all current and previous COACHES or OTHER HELPING PROFESSIONALS (Leadership, Life, Couples, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)

Are you a patient of Fire PT, Root PT & Wellness, Genesis PT & Wellness, or any other pelvic floor physical therapy providers?

Yes

If yes above, who is your provider?

Are you a patient Alive and Well, Aspire Women's Health, or Evergreen Functional Collective?

Yes

If yes above, who is your provider?

Referral Source

Please tell us how you found our office?*

Who referred you to Kimberly? (Type 'NA' if none.)*

Is the party listed above another professional provider? (Coaching, counselor, doctor, etc.)

Yes

Reason for Seeking Services

Please briefly describe reasons for seeking counseling based on the above choices.

Kimberly Galindo PLLC Appointments/Phone Calls will be scheduled by appointment only.

If you are ever in a state of emergency, call 911 or go to the nearest emergency room for emergency services.

Emergency and immediate services are not services provided. The following local resources are alternative options for potential clients who find themselves needing higher levels of care:

EMERGENCY RESOURCES

Dallas County MHMR 877-283-2121
Tarrant County MHMR (817) 569-4300
Collin County MHMR Lifepath Systems (Collin County MHMR) (972) 562-0190
24/7 Crisis Text Line Text “NAMI” to 741-741
National Suicide Prevention Lifeline 1-800-273-TALK (8255) or 1-800-SUICIDE (1-800-784-2433)
Parkland Hospital Psychiatric Emergency 214-590-8000
SAMHSA's National Helpline. (800) 662-4357
The Turning Point Rape Crisis Center Crisis Line 1-800-886-7273
Dallas Area Rape Crisis Center (972)-641-7273
Hope’s Door 24-Hr Hotline (Collin County) (972) 276-0057
Family Place 24-Hr Crisis Line (Dallas County) (214) 941-1991
Genesis Women’s Shelter Hotline (214) 946-4357
Carrollton Springs 24 Hr Hotline (972) 885-3795

Location

Kimberly currently offers therapy services both online throughout Texas and in person in Plano, TX. While client preferences for service format will be honored when possible, all clients are expected to consent to receiving services in both formats—online and in person—regardless of preference.

Fees

Kimberly is a fee-for-service provider. She is not listed on any insurance panels and has opted out as a Medicare provider. Her current therapy fees are listed below:

$350 / Individual/Couples Intake Session (75 minutes)
$300 / Individual/Couples Therapy Assessment Sessions (50 minutes)
$300 / Couples/Sex Therapy Sessions (50 minutes)
$250 / Individual/EMDR Sessions (50 minutes)

Sliding-scale fees and pro bono services are available upone request and in a limited capacity and are offered on a first-come, first-served basis. They cannot be guaranteed.

Contact Anna at info@annastubbs.co for more information on coaching fees and packages, speaking and training fees, and educational content and product fees.

Do you have insurance (healthcare coverage)?

Yes

Are you eligible for Medicare Benefits?

Yes

Kimberly Galindo, LPC-S, CST does not currently participate as a provider with insurance plans and is a fee-for-service, or private pay, practice. We are required by law to ask if you have insurance either way.

Please indicate your available for scheduling. Kimberly offers day time availability during the week. Generally, morning is considered 9 a.m. to noon and afternoon is considered noon to 5 p.m. Kimberly has limited evenings and weekends available.

Your information will be encrypted.

Inquiry Form

History of Professional Services & Care

Referral Source

Reason for Seeking Services

Kimberly Galindo, PLLC