Developmental Counseling FORM
For
use this form, see FM 6-22; the proponent agency in TRADOC.
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DATA REQUIRED BY THE
PRIVACY ACT OF 1974
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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: The
DoD Blanket Routine Uses set forth at the beginning of the Army’s compilation
of systems or records also
apply to this system
DISCLOSURE: Disclosure is voluntary.
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Part I - Administrative
Data
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Name
(Last, First, MI)
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Rank/Grade
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Date
of Counseling
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Organization
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Name
and Title of Counselor
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PART II - Background
Information
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Purpose of Counseling: (Leader states the reason for the
counseling, e.g., Performance/Professional or Event-Oriented counseling and
includes the leader’s facts and observations prior to the counseling):
• Inform soldier of
possible consequences for continued non-payment
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Part III - Summary of Counseling
Complete this section during or immediately
subsequent to counseling.
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Key Points of
Discussion
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It has been brought to my
attention that you currently have a debt with:
1. Rent-a-Center in the amount of $532.00, dated: 25
December 2004
As a soldier you have an
obligation to pay your debts in a timely manner. Failure to do so reflects negatively upon
you, the Unit, and the United States Army.
I am giving you until DAY/DATE to provide me with proof that you have
paid this debt in full or bring me written confirmation that you have
established a plan with the creditor to pay the debt. This is your 1st offense concerning
financial debts. After considering all
the facts concerning you financial situation I am recommending to the
commander that the following actions be taken:
____ You be scheduled for a budgeting class
____ You be scheduled for a check writing class
____ Recommendation of bar to reenlistment
____ Recommendation of flag (stops all favorable
actions e.g. NCOES, civilian schools, promotion, etc.)
____ Recommendation for punishment under the
UCMJ
____ Other:
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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.
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DA FORM 4856,
AUG 2010
PREVIOUSE EDITIONS ARE OBSOLETE
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):
If you are scheduled for a class or an
appointment with a financial advisor you will ensure that you bring all
bills, debts, current LES, and prepare a list of creditors (with addresses)
in the event that a loan consolidation may be suggested by the financial
counselor. The more information you
provide the better an advisor can assist you.
This is your chance to correct this situation. Failure to correct this
situation could result in adverse action (flags, bars, UCMJ) and/or chapter
from the military.
Soldier provided the following reasons
for the failure to pay debt:
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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):
• Check receipt of payments/agreement of
payment
• Conduct follow up counseling
• Ensure
Soldier attends scheduled classes
Signature of Counselor:
_________________________________________ Date:
_____________________
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Part IV - ASSESSMENT OF
THE PLAN OF ACTION
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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: _____
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Note: Both the counselor and the individual
counseled should retain a record of the counseling.
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DA FORM 4856,
AUG 2010
