( This document is considered Controlled Unclassified Information (CUI) when filled.

DEVELOPMENTAL COUNSELING FORM

For use of this form, see ATP 6-22.1; the proponent agency is TRADOC.
PRIVACY ACT STATEMENT
AUTHORITY: 5 USC 301, Departmental Regulations, 10 USC 3013, Secretary of the Army.
PRINCIPAL These records are created and maintained to manage the member's Army and Army National Guard service effectively, to document historically a member's
PURPOSE: military service,and safeguard the rights of the member and the Army.
NOTE: For additional information, see the System of Records Notice A0600-8-104b AHRC, https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/
Article/570051/a0600-8-104b-ahrc/.
ROUTINE USE(S): There are no specific routine uses anticipated for this form; however, it may be subject to a number of proper and necessary routine uses identified in the system of
records notice specified in the purpose statement above.
DISCLOSURE: Disclosure is voluntary.

PART I - ADMINISTRATIVE DATA

Name (Last, First, MI) Rank/Grade Date of Counseling
GRAFF PATRICK ROBERTMATTHEW SPC / E4 20230807
Organization Name and Title of Counselor
WZ3VAA, 321 EN CO SFC Michael Kirkland ARCC
PART II - BACKGROUND INFORMATION
Purpose of Counseling: (Leader states the reason for the counseling, e.g. Performance/Professional/Event-Oriented counseling, and include the leader's facts
and observations prior to the counseling.)
Approach: Non Directive Combined Directive

Type of Counseling: General Form Professional Growth Performance Event Oriented

<RXDUHEHLQJFRXQVHOHGRQ\RXUGHVLUHWRWUDQVIHUIURPD7URRS3URJUDP8QLW738WRWKH,QGLYLGXDO5HDG\5HVHUYH,55

20230814 20250814
<RXUFRQWUDFWXDOREOLJDWLRQHQGVBBBBBBBBBBBB<RXUVWDWXWRU\REOLJDWLRQHQGVHQGHGBBBBBBBBBBBBB

7KHPDQ\EHQHILWVWKDW\RXKDYHDVDPHPEHULQWKH$UP\5HVHUYHZLOOWHUPLQDWHXSRQVHSDUDWLRQIURPD738$VDQ$UP\5HVHUYH&DUHHU
&RXQVHORULWLVP\UHVSRQVLELOLW\WRHQVXUHWKDW\RXXQGHUVWDQGWKHRSWLRQVWKDWDUHDYDLODEOHWR\RXEDVHGRQ\RXUTXDOLILFDWLRQVVXFKDVWKH
,QGLYLGXDO5HDG\5HVHUYH,555HWLUHGRU6WDQGE\5HVHUYH$FWLYH*XDUG5HVHUYH$*53URJUDP2IILFHU$FFHVVLRQV3URJUDPDQG
SRVVLEO\WUDQVIHUULQJWRDQRWKHU738ZLWKLQWKH$UP\5HVHUYH

PART III - SUMMARY OF COUNSELING

Complete this section during or immediately subsequent to counseling.
Key Points Discussion:

<RXDUHEHLQJFRXQVHOHGRQ\RXUGHVLUHWRWUDQVIHUWRWKH,55<RXKDYHUHDGDQGVLJQHGWKHWKH6WDWHPHQWRI8QGHUVWDQGLQJ628'$)RUP

<RXKDYHDOVREHHQJLYHQGLUHFWLRQWR+5&
V,55,0$3URJUDP0DQDJHPHQWZHESDJHKWWSVZZZKUFDUP\PLOFRQWHQW,QGLYLGXDO5HDG\
5HVHUYH,55a),0$3URJUDP0DQDJHPHQW,0$

 6ROGLHULVDZDUHWKDWEHQHILWVUHFHLYHGIURPWKH86$5ZKLFKDUHFRQWLQJHQWXSRQVHUYLFHLQWKH86$5VXFKDV7XLWLRQ$VVLVWDQFH7$6WXGHQW

/RDQ5HSD\PHQW6/53DQGWKH0RQWJRPHU\*,%LOO6HOHFWHG5HVHUYH&KDSWHUZLOOFHDVHXSRQDVVLJQPHQWWRWKH,55
 2QO\$UP\5HVHUYH6ROGLHUVRQGULOOLQJVWDWXVDUHHOLJLEOHIRU75,&$5(5HVHUYH6HOHFW
 6ROGLHULVDZDUHWKDWHQWLWOHPHQWWRDQ\UHHQOLVWPHQWLQFHQWLYHVPD\EHWHUPLQDWHGDQGDQ\XQHDUQHGSRUWLRQVRIWKHVHLQFHQWLYHVPD\EHUHFRXSHG
XSRQDVVLJQPHQWWRWKH,55
 6ROGLHULVDZDUHRIWKHUHTXLUHPHQWWRXSGDWHSHUVRQDOFRQWDFWLQIRUPDWLRQZKLOHDVVLJQHGWRWKH,55DQGWKDWFDQEHGRQHE\FRQWDFWLQJ+5&RUORFDO
$UP\5HVHUYH&DUHHU&RXQVHORU$5&&
 6ROGLHULVDZDUHWKH\PD\EHPRELOL]HGRUGHSOR\HGZKLOHDVVLJQHGWRWKH,55
 6ROGLHULVDZDUHRIWKHSURFHVVWRFRPHEDFNLQWRD738
 $SHULRGRIQRQDYDLODELOLW\LVDXWKRUL]HGWRVROGLHUVXSRQDSSURYDOIRUWUDQVIHUWRWKH,QGLYLGXDO5HDG\5HVHUYHIRUSHUVRQDOUHDVRQVIRUXSWRRQH
\HDU5HLQVWDWHPHQWRILQFHQWLYHHOLJLELOLW\ZKHQDXWKRUL]HGUHTXLUHVH[WHQGLQJWKHWHUPRIVHUYLFHHTXDOWRRUJUHDWHUWKDQWKHSHULRGLQDQRQDYDLODEOH
VWDWXVZLWKLQGD\VRIUHDVVLJQPHQWEDFNWRD738,$:8QGHUVWDQGWKDWWKHHOLJLELOLW\LVFRQWLQJHQWXSRQUHWXUQLQJWRWKH026IRUZKLFK
RULJLQDOO\FRQWUDFWHGRUDQ026DQGRUXQLWUHPDLQLQJRQWKHDSSURYHGFULWLFDOVKRUWDJHOLVWIRUERQXVHOLJLELOLW\

Upon your transfer to the IRR or separation from the Army Reserve you forfeit the following.
►Part-Time Income
►Education Tuition Assistance $4000.00 per year or up to 16 semester hours per fiscal year $250.00 per credit hour x 4 years = $18,000.00
►MGIBill-SR 1606 ($407 a month for 36 months=$14,652) terminates when service member separates resulting in break-in-service or remains more
than 12 months (exception for Missionary Obligation up to 3 years) in the IRR. Cannot be used while in the IRR.
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, MAR 2023 ( This document is considered Controlled Unclassified Information (CUI) when filled. ) APD AEM v1.00ES Page 1 of 2
PREVIOUS EDITIONS ARE OBSOLETE.
 ( This document is considered Controlled Unclassified Information (CUI) when filled. )
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 specified time line for implementation and assessment (Part IV below).

 .HHS\RXUFKDLQRIFRPPDQGLQIRUPHGRIDQ\FKDQJHRISODQVDQGSURYLGHDFRS\RIWKLVFRXQVHOLQJIRU\RXUWUDQVIHUSDFNHW

 ,QLWLDWH\RXUUHTXHVWWRWUDQVIHUWRWKH,55DVDSSURSULDWHDQGSURFHVVUHTXLUHGSDFNHWLQDFFRUGDQFHZLWK\RXUXQLW
V623DQG3$*JXLGDQFHKWWSV
[WUDQHWXVDUFXVDUSDJ3DJHV&KHFNOLVWDVS["DFWLRQ 7$

 &RQWLQXHWRDWWHQG%$XQWLOHIIHFWLYHGDWHRIWUDQVIHURUGHUVRUSURSHUO\UHOHDVHGE\XQLWFRPPDQGHU

 )XOO\RXWSURFHVVSHUXQLW
V623

 (QVXUHDOOFXUUHQWFRQWDFWLQIRUPDWLRQLVSURSHUO\DQQRWDWHGLQWKHDSSURSULDWHSHUVRQQHOV\VWHPV

►If awarded during a enlistment/reenlistment a Student Loan Repayment Program cannot be used while in the IRR or when you separate from the
Army Reserve. N/A
►Unserved Term of Service of the Enlistment/Reenlistment Bonus: _N/A___ is subject to be terminated and/or recouped in accordance with your
bonus addendum.
►Tricare Reserve Select Health Insurance: $46.70 a month (Sponsor only) / $229.99 a month (Sponsor & family)
Deductible: (E4 and below: $52 for Sponsor/$105 for family) (E5 and above: $ 158 for Sponsor/$317 for family) ►Tricare Dental: $11.39 Sponsor
only/ $85.44 Sponsor and family ►Retirement with Healthcare. SFC with 5550 points receives $2,092.47 a month ►TRICARE Select, Retired No
premiums/Deductible $150 per year (Sponsor only) or $300 (Sponsor & family)
►Investments toward Thrift Savings Plan (TSP) ►Solider Group Life Insurance (SGLI): $500,000 Life Insurance Policy

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:

Soldier has completed contractual obligation and wishes to transfer to the IRR to focus on family and civilian career.

Signature of Individual Counseled: DATE (YYYMMDD)

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

Army Reserve Career Counselor: SFC Kirkland, Michael W., Mobile: 713-826-5682 Email: michael.w.kirkland2.mil@army.mil
Area Leader Name: MSG Williams, Manuel L., Office: 719-317-2380 manuel.l.williams.mil@army.mil

Signature of Counselor: Date (YYYMMDD)

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.)

SIGNATURES
Counselor: Individual Counseled: Date of Assessment (YYYMMDD):

Note: Both the counselor and the individual counseled should retain a record of the counseling.
DA FORM 4856, MAR 2023 ( This document is considered Controlled Unclassified Information (CUI) when filled. ) APD AEM v1.00ES Page 2 of 2