Schedule an Appointment
Schedule an Appointment

Blues and Soul Psychiatry Care in Memphis, Tennessee

Let us help you navigate your path to mental wellness.

Schedule an Appointment

Controlled Substances Agreement

The following agreement relates to my use of controlled substances including but not limited to benzodiazepines, stimulants, sleep aides, and buprenorphine. I will be provided with prescriptions only if I understand and agree to the following;
  1.  I understand that, depending on the drug and dose, I can become physically dependent on the medication and can develop withdrawal symptoms if medication is stopped suddenly or the dose is reduced rapidly. Although the risk is small there is a chance of developing an addiction to controlled substances. Controlled substances can cause sedation, confusion, or other changes in mental state and thinking abilities. I understand that the decision to drive while I am taking controlled substances is my own decision and i agree not to be involved in.
  2. I will not use any illegal controlled substances including, but not limited to marijuana and cocaine. I will not drive while intoxicated with alcohol.
  3. The office policy regarding the dispensing of controlled substances requires that I be seen regularly and I agree to make and keep my appointments. I will advise my doctor of all other medications and treatments that I am receiving. I consent to lab tests and routine monitoring as recommended by my clinician.
  4. If the medications require adjustment, an appointment must be made to see the Physician. No adjustments will be made over the telephone. My careful planning is required. I understand that medication refills and adjustments are only done during office appointments except under unusual circumstances. I must stay with the prescribed dosing so that I do not run out of medication early. The medication is expected to last until the GOOD UNTIL date that is found on the prescription bottle and/or package. I understand that the office policy is not to prescribe medications early, I may have to go without medication until my next prescription is due, possibly resulting in withdrawal symptoms.
  5. I understand that the prescriptions are my responsibility once they are placed in my hand and that if anything happens to my prescriptions (lost, stolen, accidentally destroyed) I may not receive a replacement prescription written from my physician. The office expects me to file a police report if my medication is stolen. I will be prepared to bring in a copy of a police report at my next office visit.
  6. Females Only- Because of the risk of certain medications to unborn children, I will inform all physicians immediately if I become pregnant or decide to try to become pregnant. I am aware that should I carry a baby to delivery while taking these medications, the baby may be physically dependent on these medications. I am aware that there is a risk of birth defects while on these medications. However, birth defects can occur whether or not the mother is on medication and there is always the possibility that my child will have a birth defect.
  7. I understand that in general I may be weaned off my medication or my drug therapy may be terminated at the discretion of my physician if any of the following occur:
  • It is the opinion of my physician that controlled substances are not very effective for my pain and or my functional activity is not approved,
  • I misuse the medication,
  • I develop a rapid tolerance or loss of effectiveness from my treatment,
  • I develop side effects that are significant and detrimental to me,
  • I obtain controlled substances from sources other than my psychiatrist without informing them,
  • I am arrested and/or convicted for a controlled or illicit drug violation including but not limited to drunk driving or driving while under the influence of a controlled substance,
  • Any violation of this agreement.

Practice Policies

The following information is provided to our patients to assist in understanding the policies and procedures at our office. We strive to provide you care which is both comfortable and of the highest quality. Attached to this Patient Agreement is the required Notification of Patient Rights document now required with the passage of the federal “Medical Records Privacy Act” known as HIPAA.
We are required by law to give you a copy of this document and to secure your signature indicating you have received a copy of it. Laws such as these are important and we have tried to inform you about your rights in plain simple language. Please read this agreement and do not hesitate to ask any questions you might have about this information.

No Surprise Billing: Based on the No Surprises Act passed by Congress, all clients will be protected from surprise bills for emergency services if BSP, or any of its providers, are deemed out of network; and will only be held liable for in-network cost-sharing amounts. This, also, allows uninsured clients to receive a good faith estimate of the cost of care.

Appointments

Patients are seen by appointment only unless an emergency situation dictates otherwise- the appointment time given is reserved for you. Please give at least twenty-four (24) hours notice if you must cancel your appointment. Sometimes illnesses and emergency situations happen which prevent you from keeping your appointment and we are understanding of these infrequent occurrences but please call as soon as you can.
  • In the absence of such circumstances, you will be charged a no-show fee with a minimum of $50.00 up to the fee for your scheduled appointment for any appointments not canceled 24 hours in advance. Please understand that insurance companies will not pay this fee- it will be your full responsibility to pay these charges. These charges will be due prior to scheduling another appointment. If you miss three or more appointments you may be discharged from the office.



  • Failure to cancel your appointment providing 24 hours advance notice, you will be charged a no-show fee of $50.00 for a follow-up appointment or a no show fee of $100 for a new patient appointment.

Fees and Payments

Co-payments, deductibles and/or outstanding balances are due at the time of service. If necessary payment arrangements can be made for larger balances and such agreements will have to be honored in order to continue treatment. There may be special fees for certain services such as filling out paperwork, court appearances, consults, etc and will be discussed with you prior to the service being provided.
All accounts that require the need for a collection agency and/or attorney involvement for payment will be assessed an additional penalty of 50% of the outstanding balance. Call at least 2-3 days prior to running out of medication in case there are issues with your request.

Completion of Family Medical Leave Act (FMLA)/Leave Of Absence (LOA)/ Disability paperwork: There is a separate fee of $50 for the initial completion of forms.


Client is also subject to pay an additional $35 for subsequent completions/extensions of FMLA/LOA forms as well.

Telephone Calls and Emergencies

Although you have regularly scheduled appointments, there may arise occasions when you need to talk to us between appointments. Please call during regular office hours and we will return your call as soon as we can. If you leave a message that the office staff can not handle we will forward your message to your physician and you will receive a call back when he responds to your message. Please remember that the physician is not always readily available due to seeing patients in the office or not in the office at the time of your call. If your call is an emergency please inform the staff immediately.

We have twenty-four (24) hour coverage for emergencies outside normal office hours. Please use this service for emergencies only. If the on-call staff is called on your behalf after hours you may be charged a minimum $35 fee up to $75 depending on the length and type of call. If the on-call staff is notified and your call is not an emergency you will be charged a $35 fee for a non-emergency call back even if your request is not granted. Please remember that medication refills are not emergencies. Insurance companies will not pay this fee- it will be your full responsibility to pay these charges. These charges will be due at your next appointment or prior to scheduling another appointment.

Prescription Refills

Your physician should provide you with enough medication and refills until your next appointment. If you need refills due to missed or rescheduled appointments please call the prescription line and leave detailed information including your name, your call back number, your doctor’s name, pharmacy phone number, medication needed and dosage. If you need an appointment or have an outstanding balance, this will need to be handled prior to refilling any medications. Please understand that routine medication refills will not be called in after hours or on the weekends.

Insurance Usage - Issues of Confidentiality/Privileged Communication

If you elect to have your third party insurance filed, you will be signing a release of information to our billing service. This service handles all claims, statements and information on your account until your account balance is zero. The following information will be forwarded for this purpose- your personal identify information, your insurance information, dates and length of sessions, diagnosis and office notes if required by your insurance carrier.

As you know insurance company policies have changed tremendously in regard to reimbursement for service. Many plans require initial pre-certification of care before you can use your benefits. It is your responsibility to make sure such pre-certification requirements are met by you if you elect to use your insurance benefits (i.e. if you have any “gate keeping” mechanisms such as calling insurance for approvals) Nearly all insurance companies will require participation in utilization review procedures. We will be giving your insurance carrier only the information that is necessary to certify care and reimbursement.

With these exceptions, unless you specifically sign a release of information authorizing us to talk to someone, all communications here are kept private, confidential and privileged. We strive to maintain the sacredness and privacy of your confidential communications with us.

Patient and/or Guardian Responsibility Waiver

We have your insurance claims filed as a courtesy to you; it is your responsibility to notify this office when you have a policy/insurance change or information update.

This includes your personal address and phone number. We want to be clear that if you do not notify this office of your insurance changes and updates within your timely filing limits, you are responsible for the balance on the account.

This signed agreement between you-the patient and/or guardian/guarantor supersedes all other contractual obligations we may have with your insurance carrier in accordance with timely filing of your claims.

Your Informed Consent to Care and Treatment

We have provided this information to you in the hopes of fully informing you about the policies of this office and some of the parameters of care you will receive here, such as the importance of confidentiality. Since such limitations are always a function of your particular problem in question, we invite you to discuss your treatment plan with us. After we have met to discuss your concerns we will construct an individualized treatment plan and share it with you so that we have a plan and goal for the problems we are going to address. Should you have any questions please feel free to discuss any of these matters with us in more detail.

By signing the PATIENT AGREEMENT FORM you acknowledge to having read, understood and agreeing to these policies and procedures. Your signature also acknowledges your informed consent for treatment

Patients Rights

What are your rights?
  • You have the right to be informed about the care you will receive.
  • You have the right to get information about your care in your language.
  • You have the right to make decisions about your care, including refusing care.
  • You have the right to know the names of the caregivers who treat you.
  • You have the right to safe care.
  • You have the right to have your problem treated.
  • You have the right to know when something goes wrong with your care.
  • You have the right to get an up-to-date list of all of your medications.
  • You have the right to be listened to.
  • You have the right to be treated with courtesy and respect.
  • You have the right to determine who you will grant access to your personal
  • health information.
  • You have the right to revoke the release of your personal health information at any time.

Speak up if you have questions or concerns, and if you don’t understand, ask again. It’s your body and you have the right to know.


Pay attention to the care you are receiving. Make sure you’re getting the right treatments and medications at our office.


Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan.


Ask a trusted family member or friend to be your advocate.


Know what medications you take and why you take them. Medication errors are the most common healthcare error.


Use a hospital, surgery center or other type of health care organization that has established quality and safety standards.


Participate in all decisions about your treatment. You are the center of your healthcare team.

Contact Us

The Power of Opening Up

Get in touch with us and start your journey of healing.

Please be advised that email correspondence is for the purpose of basic information regarding the clinic and acceptance of new patients. This email will be checked by Dr. Shakti's staff periodically. They are not clinically trained. Please do not send emails regarding acute medical or psychiatric issues. The staff will only be able to respond to questions regarding the procedures and policies of the clinic. Thank you and we welcome correspondence from you.

At Blues & Soul Psychiatry it is our mission is to empower our patients to achieve mental wellness by delivering innovative, evidenced based treatment in a professional and compassionate environment.

Important Links
Patient Information
About

Designed with ❤ and ☕️ in NYC by D.A.S. Consultants.

We know, so much text, but this information is key - don't worry we got a way to go to the top.

Go to Top