MEDA's Initial Inquiry Form
Please input information requested below. We do our best to respond to your inquiry in one - two business days.
Your First and Last Name
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Your Email:
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example@example.com
Phone Number
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Area Code
Phone Number
Your Phone Number:
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Are you looking for services for you or someone else?
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Me
Child 17 or younger
Child 18 or older
Referring a Client
Other
Their First and Last Name:
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Their relationship to you:
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Client email:
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Client phone:
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Address of person seeking services
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pronouns of Client:
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She / Her
He / Him
They / Them
Other
Date of Birth of Client:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What services are you looking for (check all that apply):
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Assessment
Individual Therapy
Therapy Groups
Skills Coaching Session
Family Therapy
Family Coaching Sessions
Nutrition
Referrals
I am not sure
Other
What Therapy Groups are you interested in:
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Getting Unstuck Group
EmbodiED
Shame Resilience
Multi-Family Parent Psychotherapy Group
Healing Trauma and Body Image Group
Living Large in Recovery
Body Image Group for Teens (15-17 years old)
Body Image Group for Young Adults (18-22 years old)
Approaching Body Neutrality Group
Almost Recovered Group
Introduction to Intuitive Eating
Men’s Psychotherapy Group
Recovery on Campus
LGBTQ+ Group
Teen Recovery Group
Root and Rise: Intuitive Eating for Body Compassion
Transmasc Body Image Group (18+)
Aging with an Eating Disorder – Finding Connection and Healing Later in Life (50+)
Adult Body Image Therapy Group (18+)
Nourish the Season (18+)
Light Within the Season: Healing, Nourishment, and Connection (18+)
Other
Do you have an individual therapist?
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Yes
No
I (or my child / guardian) would like to be seen (Please note: that our groups are currently only offered virtually):
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Virtually via Zoom
In-person at MEDA's offices in Newton
A combination of virtual and in-person
Brief description of concern / need:
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How will you be paying for your services?
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In Network Insurance (MEDA currently is in network with Aetna, Blue Cross Blue Shield, CIGNA, Optum Companies - Harvard Pilgrim, UBH, Health Plans Inc, Tufts Health Plans and Medicare.)
Out of Network Insurance
Self Pay
I would like to request sliding scale
I would like to apply for a scholarship
Health Insurance Provider
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Please upload a copy of the FRONT of your insurance card
*
Browse Files
Cancel
of
Please upload a copy of the BACK of your insurance card
*
Browse Files
Cancel
of
How did you learn about MEDA?
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Web Search
Referral from PCP/Therapist/Dietitian
Treatment Facility
Friend / Family
Social Media
Other
If you were referred by a PCP / Therapist / Dietitian or Treatment Facility, please indicate who:
I would like to be added to MEDA's e-newsletter list.
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Yes
No
I am already on your list
Anything else you would like us to know?
Submit Form
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