VPMC Mental Wellness — Referral
Provider line (571) 206-8696 · Electronic referral: Virginia Premium Medical Care (Privia Medical Group). We schedule within 48 hours and send a summary after the first visit.
| Patient name | Date of birth | ||
| Patient phone | Insurance | ||
| Referring provider | Practice / phone |
Reason: ☐ Anxiety ☐ Depression ☐ ADHD evaluation ☐ Insomnia ☐ Postpartum / perimenopausal mood ☐ Teen (16–17) ☐ Medication management takeover ☐ Other: ______________
Urgency: ☐ Routine (within 14 days) ☐ Urgent (within 7 days)
Notes: ________________________________________________________________
☐ Send summary to referring provider
This form is for providers. Patients: please book online or call us directly rather than sending health information by email.