The Application Process

1
Name* This field is required.
First Name
Last Name
2
Which city/country do you live in?
3
Cell Phone Number* This field is required.(this is only for direct communication between you and I regarding your care)
Please enter a valid phone number.
4
Email Address where I can reach you* This field is required.(this is only for direct communication between you and I regarding your care)
example@example.com
5
How did you discover me/this program?* This field is required.Was there a specific video or post that resonated with you and made you want to apply? What was the title or topic?
6
Have you had acupuncture before?* This field is required.
Yes - I am familiar with acupuncture/Eastern Medicine and have used it often
Yes - once or a few times, but I didn't get results so I never really got into it
No, never
7
Have you taken herbal medicine before?* This field is required.
Yes, many different Eastern Medicine herbal formulas
I've only used single herbs (for example: ashwagandha, milk thistle, turmeric/curcumin)
I've never tried herbal medicine
8
My birthdate is...* This field is required.
9
Which of these best describes your goals here?* This field is required.
I’m here to learn and improve my own health
I want to understand Eastern Medicine better to use with my clients, and I have some health issues I'd like to work on too
I’m sick and tired of being unwell and I need change
10
Which best describes your attitude towards healing? Be honest!* This field is required.
I'm open and ready for new solutions, and I believe there's a way for me to feel better
I'm burnt out from trying and failing, but still cautiously optimistic there’s hope
I'm just here to learn more
11
How much are your symptoms (physical and/or emotional) interfering with your life?* This field is required.
My symptoms interfere significantly, but I still push through to have the fullest life possible
My symptoms interfere significantly, and I’ve given up doing so many things that I used to enjoy
My symptoms are mild and rarely interfere with my life
12
Please mark the symptoms you experience* This field is required.select all that apply
fatigue/exhaustion
Chronic pain
Brain fog
Sleep trouble
Sweating at night
Digestive issues
Anxiety
Depression
Hormonal issues
Painful Periods
Difficulty getting or staying pregnant
Inflammation
Too cold
Too hot
Weather sensitivity
Headaches
Allergies
Other
None of these
13
What are the top 1-3 things you’d like help with regarding your health? How long have you had each of these conditions? * This field is required. please describe your most difficult symptoms or issues
14
Please list everything you’ve tried in the past to improve your health related to this condition. Approximately how much did each cost? Have these methods/treatments helped? Which ones are you still taking/doing?* This field is required.(practitioners, programs, courses, retreats, medications, supplements, products, etc.)
15
What are your health goals?* This field is required.please be as detailed and specific as possible
16
What are some of your biggest challenges to your healing right now? What’s blocking you from getting better?* This field is required.
17
Please share something you believe to be true about your current health situation that may be controversial or that others don’t necessarily understand.* This field is required.Please be as detailed and specific as possible.
18
If we were sitting down and talking a year from now, what would have needed to change for you to feel successful with your health?* This field is required.Please be as detailed and specific as possible.
19
What do you do for work? Do you like your work?* This field is required.
20
In general, when I was a child my emotions were...* This field is required.mark all that apply
typical. I had the usual flares of high emotions that kids tend to have because they're just learning how to feel and regulate, but generally remember feeling happy and supported.
intense and frustrating. I regularly felt emotionally overwhelmed and misunderstood.
extreme and chaotic. I often felt frightened, destabilized, or in emotional pain.
shut down. I don't remember feeling that much or I was encouraged not to express big emotions. I dissociated often or played/went into my own isolated fantasy world.
21
Are you vegetarian or vegan? Specify what your motivations are and for how long you’ve eaten this way. Are you open to incorporating animal products into your diet if your body and health goals require it?* This field is required. If you have a specific diet/way of eating that you're currently following or that's important to you, but you are not vegan or vegetarian, please use the space below to describe that.
If this doesn't apply to you, please just write "I eat meat."
22
Are there any unique factors I should know about your case while considering your application?* This field is required.
23
Do you have any questions for me?
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24
I understand that there are no refunds for this program, and I certify that I have made the choice as a self-responsible adult to opt in and purchase this Health Mentorship.* This field is required.
YESNO
25
By typing my electronic signature below, I certify that the information provided in this intake form is true, accurate, and complete to the best of my knowledge and belief.* This field is required.
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26
Select Your Program* This field is required. Please rest assured that your card will not be charged until I have reviewed and approved your application.
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ORDER SUMMARY
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Yin Medicine A 6 month 1:1 intensive health mentorship with Liana Russo, L.Ac - Learning and practicing Eastern Medicine principles and techniques personalized to your health needs for multilevel healing and deep relief. Custom herbal medicine included.
$4,499.00Edit
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The Tending FieldA 3 month 1:1 container with three 1:1 calls + two 1:1 15 minute consults, personalized self-led practices, and customized herbal medicine to recalibrate back to health.
$999.00Edit
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