Intake form

Name *

Email address *

What is your primary goal on loser 2.0?

Please select at least one option.

Weight loss

Reading books

Quitting addiction

How did you hear about us?

What is your current weight?

What is your target weight?

What types of books do you enjoy reading?

Please select at least one option.

Fiction

Non-fiction

Self-help

Biography

Science fiction

Fantasy

Mystery

What addictions are you seeking to quit?

Please select at least one option.

Smoking

Alcohol

Sugar

Gambling

Social media

How many times a week do you exercise?

What is your preferred method of tracking your progress?

What challenges do you anticipate in your journey?

Additional questions or comments

Loser 2.0