Fillable Printable Sample Army Counseling Form

Sample Army Counseling Form

DEVELOPMENTAL COUNSELING FORM

For use of this form see FM 22-100.

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)

PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.

ROUTINE USES: For subordinate leader development IAW FM 22-100. Leaders should use this form as necessary.

DISCLOSURE: Disclosure is voluntary.

PART I - ADMINISTRATIVE DATA

Name (Last, First, MI) Rank / Grade

SPC/E-4

Social Security No. Date of Counseling

1 APR 12

Organization

ABN DIV

Name and Title of Counselor

SGT LAMOREAUX, PAT/ SQUAD LEADER

PART II - BACKGROUND INFORMATION

Purpose of Counseling: (Leader states the reason for the counseling, e.g. Performance/Professional or Event-Oriented

counseling and includes the leaders facts and observations prior to the counseling):

- Event-Oriented Counseling

- Violation of Article 91- Insubordinate conduct toward a non-commissioned officer

- Violation of Article 117- Provoking speeches or gestures

- Violation of Article 134- Disorderly conduct

PART III - SUMMARY OF COUNSELING

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

SPC D******, you are hereby being counseled for Violation of the following articles: Article 91, Article 117 and Article 134. On

1 April 12, at 0600 hrs, you showed up for PT formation and when you walked in the door I told you to do push-ups for not

signing in from leave the night before. You rolled your eyes and told me that you were not going to do it and that you didn’t have

to. Even when I talked to you in private to determine if there were any extenuating circumstances, you still did not cooperate. I

then told you to stand at parade rest and you shrugged it off and ignored me. In addition, when SFC Smith, a senior non-

commissioned officer, pulled you into the office to talk to you, you did the same thing and was disrespectful.

This insubodination will not be tolerated . I don’t think you realize the situation you have put yourself into or the repercussions

that could result. You get out of the Army at the end of the year and all you have to do is follow the rules and stay out of trouble

to end your career on a good note. Instead you have adopted an uncooperative attitude. I am here to help you but if you don’t

care, I can’t help you. The bottom line is that this type of behavior is unbecoming of a Soldier in the United States Army and

will not and cannot be tolerated.

In addition to being counseled on the points above, he received counseling on the following: (1) That continued behavior similar to that for

which he has been counseled may result in punishment under Article 15, UCMJ, court-martial, or adverse action such as a bar to reenlistment,

suspension of favorable personnel actions (promotion, retention, school), or other appropriate administrative sanctions; (2) That if this behavior

continues that separation under the provisions of AR 635-200 may be initiated; (3) That if separated prior to ETS, that he could receive either an

honorable, general, or other than honorable discharge for their current term of service, or their term of service would be uncharacterized if they

have served less than 180 days on active duty; (4) The basis for each characterization of service and the discharge certificates received for each

and that his character of service would become part of a permanent record and may be provided to any Federal agency if they were to apply for

either federal employment or security clearance; (5) The possible effects that each type of discharge would have on reenlistment, civilian

employment, veterans benefits, and related matters; (6) That a general discharge would cause loss of civil service retirement credit; (7) That an

other than honorable discharge would result in him being reduced to the lowest enlisted rank, loss of payment of accrued leave, and loss of all

benefits administered by the Veterans Administration and other federal and state agencies; (8) That separation prior to ETS may preclude him

from enlisting in any component of the Armed Forces; (9) That separation prior to ETS may cause him to lose their entitlement to education

benefits and money paid into the Army College Fund; (10) That separation prior to ETS may cause him to repay any unearned bonus received

for enlistment or reenlistment; (11) That it would be unlikely that any attempt to have his characterization of service upgraded would be

successful; (12) That he is encouraged to make every reasonable effort to ensure his performance and conduct meet military standards; (13) That

he would be given a reasonable effort to bring their substandard performance and conduct to acceptable military standards.

OTHER INSTRUCTIONS

This form will be destroyed upon: reassignment (other than rehabilitative transfers), separation at ETS, or upon retirement. For separation requirements and

notification of loss of benefits/consequences see local directives and AR 635-200.

DA FORM 4856-E, JUN 99

EDITION OF JUN 85 IS OBSOLETE

Plan of Action: (Outlines actions that the subordinate will do after the counseling session to reach the agreed upon goal(s).

I am recommending you to your chain of command for punishment under the Uniform Code of Military Justice. In addition, you

will type a 2,000 word essay that addresses the following areas: the importance of acting professional in everything you do, both

military and civilian, and how your actions affect others.

Session Closing: (The leader summarizes the key points of the session and checks if the subordinate understands the plan of

action. The subordinate agrees/disagrees and provides remarks if appropriate):

Individual counseled: I agree / disagree with the information above

Individual counseled remarks:

Signature of Individual Counseled: _________________________________________ Date: _____________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action):

Signature of Counselor: _________________________________________________ Date: _______________________

PART IV - ASSESSMENT OF THE PLAN OF ACTION

Assessment: (Did the plan of action achieve the desired results? This section is completed by both the leader and the individual

counseled and provides useful information for follow-up counseling):

Counselor: ____________________ Individual Counseled:_________________ Date of Assessment: ______________

Note: Both the counselor and the individual counseled should retain a record of the counseling.

DA FORM 4856-E (Reverse)