DEVELOPMENTAL COUNSELING FORM For uso of this form, s90FM 22-100; the proponent agency is TRADOC DATA REQUIRED BY THE PRIVACY ACT OF 1974 JAuTHoRITY: 5 USC 301, DepertmentalRegulations; 10 USC 3013, Secretaryof the Army and E.0, 9397 (SSN) JPRINCIPALPURPOSE: To assist leadersin conducting and recording counseling data poraining to subordinates. For subordinate loader dovelopmentlAWFM 22-100. Leaders should use this form as necessary. ROUTINE USES: Disclosureis voluntary. ‘PARTI ADMINISTRATIVEDATA Date of Counseling Rank/Grade Social Security No ‘Namoand Title of Counselor PARTI” BACKGROUNDINFORMATION Purpose of Counseling: (Leaderstates the reason for the counseling, e.g.. performence/professionajrowth or event-orientedcounseling, and includes the leader's facts and observations prior tothe counseling.) PART IN- SUMMARY OF COUNSELING Complotethls section during or immediately subsequent to counseling. ‘OTHER INSTRUCTIONS ‘This form willbe destroyed upon: reassignment (other than rehabilitative transfersl, separation at ETS, or upon retirement. For separation requirementsand notification of loss of benefits/consequencessee local directives and AR 635-200. DA FORM 4856, JUN 1999 EDITION OF JUN 5 IS OBSOLETEPian of Action (Oullines actions that tho subordinate will do aftr tho counsolig session fo Teach he agroedupon goals). The actions must be speciticencugh to modi or maintain the subordineta’s behavior and include a specified time ine fr implementationand assesment (Part IV below.) [Session Closing: (The leader summarizasthe Kay polnts ofthe session and checksit the subordinate understands the plan of action subordinate agrees/alsogreesand provides remarksifappropriste.) India couneled: [_]1 pre. [__] spree with he infrmaton above ini epurseld roars Signature of Incividal Counseled: [TeederResponslbllies: (Leader sresponsibilies In implementing the plan of action ) Signature of Counselor: PARTIV - ASSESSMENT OF THE PLANOF ACTION [Assesament: (DId the plon of action achleve the desiredresults? This section fs completedby both the leader ond the individual counseled and provides useful information for felow-up counseling) Individual Counseled Dateof Assessment: Note: Both the counselor and the individual counseled should retain a record of the counseling. "REVERSE, DA FORM 4856, JUN 1999 Teara vr