Professional Membership Application

MEDA Professional Membership Application

Please complete the form below.
Full Name*

First NameLast NameCredentials
Office Location *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Location #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Location #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different than Office Location #1 above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Can clients have access to this phone number

YesNo
E-mail (for clients)*
E-mail (personal) *
I am currently accepting new clients *

YesNo
Do you run a group? If so, we keep a comprehensive list on our website so please provide as much detail as possible so we can provide accurate information to our clients.
Would you like to join a MEDA peer supervision group?

YesNoI am already in a group
If yes, are you interested in joining a peer supervision group that meets:

VirtuallyIn-PersonHybrid
If you are looking to join a supervision group, please provide days/times that you are free

Monday morning (9-12)Monday afternoon (12-3)Tuesday morning (9-12)Tuesday afternoon (12-3)Wednesday morning (9-12)Wednesday afternoon (12-3)Thursday morning (9-12)Thursday afternoon (12-3)Friday morning (9-12)Friday afternoon (12-3)
Please outline your experience working with people with eating disorders and disordered eating.
Please upload a copy of your CV.

Browse Files

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Please upload a copy of your license(s).

Browse Files

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LETTERS OF RECOMMENDATION

If you are a new applicant please have Two Letters of Recommendation submitted. Forward this link to the people you are requesting recommendations from.

Questions, please email us at membership@medainc.org
Membership Dues - $225 for a one year membership

Group memberships (3+ individuals from the same practice. Please submit a separate application for each provider): The first member is $225 and each member is $175 after that. Please list all group members below.

3 members: $575 ($225 + $175+ $175)

4 members: $750

5 members: $925

6 members: $1,100

7 members: $1,275

8 members: $1,450
Please list all group members here:
Payment Options*

I have mailed my check payable to MEDAI have paid onlineI am part of a group membership
Click here to pay online.

Please note that you will be redirected to a different page to pay. Don't forget to submit this form after submitting your payment! If you do not recieve a confirmation email, the form did not submit properly.
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MEDA Professional Membership Application