Beau A. Nelson, MA, LCSW

 

12830 Hillcrest Road, Suite D235                                                                                                            Telephone(972) 980-9911

Dallas, Texas 75230                                                                                                                                                             Fax (972) 980-9910

 

 

Patient Name:               

 

Appointment Date:         November 3, 2008

 

 

XXX  90801 Initial Diagnostic Interview (60 min)

         90804 Individual Psychotherapy (20-30 min)

         90806 Individual Psychotherapy (45-50 min)

         90808 Individual Psychotherapy (75-80 min))

         90846 Family Psychotherapy, Patient present (45-50 min)

         90847 Family Psychotherapy, Patient not present (45-50 min)

         90853 Group Psychotherapy (45-50 min)

         90877 Consultation (45-50 min)

         90889 Report Preparation (60 min)

         Late Cancellation (50% of fee)

         No Show (100% of fee)

         Other:                                                                        

 

 

         296.21 Major Depressive Disorder, Single Episode, Mild
         296.22 Major Depressive Disorder, Single Episode, Moderate

         296.23 Major Depressive Disorder, Single Episode, Severe

         296.31 Major Depressive Disorder, Recurrent, Mild
         296.32 Major Depressive Disorder, Recurrent, Moderate

         296.33 Major Depressive Disorder, Recurrent, Severe

         300.4   Dysthymic Disorder

         311      Depressive Disorder NOS

         300.02 Generalized Anxiety Disorder

         300.00 Anxiety Disorder NOS

         300.21 Panic Disorder with Agoraphobia

         309.81 Posttraumatic Stress Disorder

         296.__ Bipolar I Disorder, _______________________

         296.89 Bipolar II Disorder

         300.3   Obsessive-Compulsive Disorder

         305.00 Alcohol Abuse

         303.90 Alcohol Dependence

         314.00 ADHD, Pred Inattentive Type

         314.01 ADHD Combined Pred Hyper-Impulsive

         301.0   Paranoid Personality Disorder

         301.20 Schizoid Personality Disorder

         301.22 Schizotypal Personality Disorder

         301.7   Antisocial Personality Disorder

         301.83 Borderline Personality Disorder

         301.50 Histrionic Personality Disorder

         301.81 Narcissistic Personality Disorder

         301.82 Avoidant Personality Disorder

         301.6   Dependent Personality Disorder

         301.4   Obsessive-Compulsive Personality Disorder

         301.9   Personality Disorder NOS

         Other:                                                                        

         Other:                                                                        

                                                                          

Beau A. Nelson, MA, LCSW

State of Texas License # 35317

NPI 1437360021

 

          November 3, 2008                                                        
 

 

Total Charges:                  200.00          

 

Payment Due:                  200.00          

 

Amount Paid:                  200.00            

 

Outstanding Balance:           0.00