EMERGENCY INFORMATION

Wilmington Mental Health
3825 Market St., Ste 4
Wilmington, NC 28411

P 910.777.5575
F 910.777.5273
info@wmhwc.com

EMERGENCY INFORMATION
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Employee:
In the case of an emergency, Wilmington Mental Health, PLLC may need to contact someone who you designated as an emergency contact. Please list the name of two individuals whom we could contact.

1. Someone in your immediate household:
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1. Someone outside your immediate household:
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AUTO INSURANCE INFORMATION

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By signing I agree that all information provided is correct. If any changes to this information occur, please notify Program Director in writing ASAP.
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