MARCH 15, 2006 FORMAT Form Approved

OMB No. 0930-0269

Expiration Date 09-30-2007

Public reporting burden for this collection of information is estimated to average 20 minutes per response; including the time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of 

information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports 

Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is 

not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this 

project is 0930-0269.

DATE: |__|__| |__|__| |__|__|__|__| START TIME: |__|__| : |__|__| END TIME: |__|__| : |__|__|

AB_MO AB_DY AB_YR AB_START AB_END

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

AB_MOM 

EVALUATION PHASE: Intake |__|1 6-months |__|4 12-months |__|5 Discharge |__|6

AB_INTERVIEW_TYPE

PERSON COMPLETING |_______________| GRANT# TI |__|__|__|__|__|

AB_INTERVIEWER AB_SITE

ALLEN BARRIERS TO TREATMENT INSTRUMENT

Listed below are reasons that sometimes keep people from getting help. Based on what you are experiencing, have 

experienced, or have heard about, how much do each of the following treatment program characteristics keep you from 

getting treatment for alcohol or other drug problems?

Check one box for each statement.

This keeps me from getting help... A lot

An average 

amount A little Not at all

AB_LACK_OF_INFORMATION

1. Lack of information about and not knowing the location of 

treatment programs ................................................................................ 4 3 2 1

AB_WAIT_OPENING_PROG_FULL

2. Having to wait for an opening because the program is full ........................ 4 3 2 1

AB_BEHAVIOR_OF_STAFF

3. The behavior of treatment program staff toward patients.......................... 4 3 2 1

AB_SPEAK_TO_MALE_COUNSELOR

4. The possibility of having to speak of my problem with a 

male counselor....................................................................................... 4 3 2 1

AB_FAR_FROM_HOME

5. The far distance of treatment programs from my home............................. 4 3 2 1

AB_NO_TRANSPORTATION

6. No available transportation to the treatment program ............................... 4 3 2 1

AB_SPEAK_WHERE_MEN_PRESENT

7. The possibility of having to speak in a group where men 

are present............................................................................................. 4 3 2 1

AB_PROGRAM_INCLUDE_MEN_WOMEN

8. Treatment programs that include men as well as women 

patients ................................................................................................ 4 3 2 1

AB_NO_HELP_STAY_ADDICTION_FREE

9. No help from treatment programs for staying alcohol and/or 

drug free afterwards................................................................................ 4 3 2 1

AB_NO_ABILITY_TEACHING_ME

10. No confidence in the ability of treatment programs to teach 

me what I need to know as an alcoholic or drug-abusing 

woman ................................................................................................ 4 3 2 1

AB_FIRST_OTH

What other things about treatment programs keep you from getting help? (Please answer in three lines or less.)

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2 0
2

Based on what you are experiencing or have experienced, how much do each of the following personal beliefs, feelings, or 

thoughts, keep you from getting treatment for alcohol or other drug problems?

Check one box for each statement.

This keeps me from getting help... A lot

An average 

amount A little Not at all

AB_FEEL_ASHAMED

11. I feel ashamed when I admit to having this problem ............................. 4 3 2 1

AB_UNABLE_STAY_FREE_AFTER_TREAT

12. In the past I have been unable to stay alcohol-free and/or 

drug-free after treatment ..................................................................... 4 3 2 1

AB_CANNOT_PAY_TREATMENT

13. I cannot pay for treatment of this problem............................................ 4 3 2 1

AB_NO_INSURANCE

14. I do not have health insurance for this problem................................ 4 3 2 1

AB_DONT_TRUST_TO_HELP

15. I do not trust doctors, clinics, or hospitals to help ................................ 4 3 2 1

AB_DRINK_DRUG_NO_PROBLEM

16. I do not feel that drinking and drug use is a problem for me.................. 4 3 2 1

AB_HEALTH_NOT_INTERRUPT_LIFE

17. I do not let health problems interrupt my life......................................... 4 3 2 1

AB_RELIGIOUS_BELIEFS

18. I have religious beliefs about this problem ........................................... 4 3 2 1

AB_HAVE_RESPONSIBILITIES

19. I have responsibilities at home as a mother, wife, or 

partner ............................................................................................... 4 3 2 1

AB_TAKE_CARE_OWN_HEALTH

20. I was raised to believe I should take care of my own health 

problems ............................................................................................ 4 3 2 1

AB_SECOND_OTH

What other personal beliefs, feelings, or thoughts keep you from getting help? (Please answer in three lines or less.)

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AB_2006-.00 3

Based on what you are experiencing or have experienced, how much do each of the following issues keep you from 

getting treatment for alcohol or other drug problems?

Check one box for each statement.

This keeps me from getting help... A lot

An average 

amount A little Not at all

AB_NO_ENCOURAGEMENT_GET_HELP

21. No encouragement from family and friends to get help for 

the problem ........................................................................................

4 3 2 1

AB_NOT_ACCEPTED_ALC_DRUG_FREE

22. Not being accepted by my friends if I am alcohol-free and/or 

drug free ............................................................................................

4 3 2 1

AB_NOBODY_CARE_FOR_CHILDREN

23. Having no one in my family or community to take care of my 

children ..............................................................................................

4 3 2 1

AB_NO_PROGRAM_HELP_STAY_FREE

24. Having no meetings or programs in my community to help 

me stay alcohol-free and/or drug free ..................................................

4 3 2 1

AB_PARTNER_ANGER_BEING_FREE

25. Anger from my boyfriend, husband, or lover for being 

alcohol-free and/or drug free ...............................................................

4 3 2 1

AB_FEAR_TAKE_CHILDREN_AWAY

26. The fear that my admission of this problem could be used by 

someone to take my children away......................................................

4 3 2 1

AB_NO_TIME_OFF_FROM_WORK

27. Not being able to get time off from work...............................................

4 3 2 1

AB_EVERYONE_EXPECTED_PARTY

28. Living in a community where everyone is expected to party 

using alcohol and drugs......................................................................

4 3 2 1

AB_PROTECTED_FROM_BAD_RESULTS

29. Being protected from the bad results of my alcohol and/or 

drug problem by friends, family or coworkers.......................................

4 3 2 1

AB_ALC_DRUGS_FOR_STRESS

30. Needing alcohol and/or drugs to deal with the stress of daily 

life in my community ...........................................................................

4 3 2 1

AB_THIRD_OTH

What other issues keep you from getting help? (Please answer in three lines or less.)

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Copyright 1991 Karen Allen

Not to be used without the written permission of Karen Allen, Ph.D.