DEVELOPMENTAL COUNSELING FORM

For use of this form, see FM 22-100; the proponent agency is TRADOC

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

5 USC 301, Department 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

Social Security No.
Date of Counseling

 

 

 

 
Organization
Name and Title of Counselor

 

 

PART II - BACKGROUND INFORMATION

Purpose of Counseling: (Leader states the reason for the counseling, e.g., performance/professional growth or event-oriented counseling, and includes the leader’s facts and observations prior to the counseling.)

 

PART III - SUMMARY OF COUNSELING

Complete this section during or immediately subsequent to counseling.

Key Points of Discussion:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You are hereby counseled for the above indicated misconduct and/or unsatisfactory performance IAW Chapter 1, paragraph 1-16, AR 635-200.  Continued behavior of this kind may result in initiation of separation action to eliminate you from the Army.  If you are separated for unsatisfactory performance, you could receive an Honorable or General Discharge.  If you are separated for misconduct, you could receive an Honorable, General or Other Than Honorable Discharge.  A General Discharge or Discharge Under Other Than Honorable Conditions could deprive you of many or all military and veteran’s benefits.  Any further act of misconduct or unsatisfactory performance may cause you to be eliminated without further counseling.

 

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 (EG), JUN 1999

EDITION OF JUN 85 IS OBSOLETE.

USAPA V1.00

 

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