1. 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, 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 Social Security No. Date of Counseling
Organization Name and Title of Counselor
710th Area Support Medical Company SGT Mintchev, Mintcho E.
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):
- Conduct initial counseling
- Encourage open communication
PART III - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to counseling.
Key Points of Discussion:
This is an initial counseling, welcoming you to 3rd Squad, Treatment Platoon of 710th Area Support Medical Company. Treatment Platoon
focuses on dispensary operations and medical treatment. 3rd Squad missions include conducting periodic health assessments, completing
physicals for deploying units, addressing medical emergencies, and mobilizing or deploying when ordered. 3rd Squad soldiers are expected
to maintain strict standards at all times.
You will be introduced to your commander, first sergeant, platoon sergeant, training NCO, readiness NCO, and supply NCO.
Once aware of your chain of command, you will understand how to address any relevant concerns of personal or military nature.
You are required to stay motivated and disciplined while performing your duties.
Failure to maintain military standards will result in punitive action on the unit’s behalf.
Attend all formations, squad meetings, and platoon meetings on time and in the proper uniform.
Expect to carry yourself as a professional and treat other soldiers as you would want to be treated.
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.
EDITION OF JUN 85 IS OBSOLETE
DA FORM 4856-E, JUN 99
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2. Plan of Action: (Outlines actions that the subordinate will do after the counseling session to reach the agreed upon goal(s). The actions must
be specific enough to modify or maintain the subordinate’s behavior and include a specific time line for implementation and assessment (Part IV
below):
The below outlined actions address your responsibilities as a 3rd Squad, Treatment Platoon member:
• Physical appearance: Ensure proper wear of your uniform in accordance with AR 670-1.
• Physical fitness: You are required to stay physically fit and pass diagnostic and record Army Physical Fitness Tests.
• Motivation and discipline: You will stay motivated, show a good work ethic, and actively participate in teamwork. You will remain an
optimistic, team-oriented individual. Adverse attitudes and behaviors will not be tolerated.
• Chain of command: You will address all issues through your chain of command. You will not utilize the unit’s open door policy prior to
attempting to solve your issues through the chain of command.
During this session, we have discussed your basic duties, responsibilities, and goals. During our next session, we will discuss you progress
towards your goals. I would also like you to look at the following areas and provide input during our next session:
• Take time to become familiar with the members of your section.
• Determine what areas you would like to work on within your section.
• During our next counseling session, we will assess this counseling.
Adhere to unit SOP
Long Term Personal Goals:
•
•
Short Term Personal Goals:
•
•
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):
• Observe the soldier’s progress in achieving the above mentioned goals
• Provide an environment to learn and grow
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)
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