Fillable A4856 DEVELOPMENTAL COUNSELING FORM

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A4856 DEVELOPMENTAL COUNSELING FORM

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Name (Last, First, MI)
Rank/Grade Date of Counseling
Organization Name and Title of Counselor
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.)
Key Points of Discussion:
DEVELOPMENTAL COUNSELING FORM
For use of this form, see ATP 6-22.1; the proponent agency is TRADOC.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army.
To assist leaders in conducting and recording counseling data pertaining to subordinates.
The DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems or records notices also
apply to this system.
Disclosure is voluntary.
PART I - ADMINISTRATIVE DATA
PART II - BACKGROUND INFORMATION
PART III - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to 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.
PREVIOUS EDITIONS ARE OBSOLETE.
DA FORM 4856, JUL 2014
APD LC v1.04ES
Page 1 of 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 specified time line for implementation and assessment (Part IV below)
Individual counseled remarks:
Leader Responsibilities: (Leader's responsibilities in implementing 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.)
DA FORM 4856, JUL 2014
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.
Signature of Individual Counseled: Date:
Signature of Counselor: Date:
PART IV - ASSESSMENT OF THE PLAN OF ACTION
Individual Counseled:
Date of
Assessment:
Counselor:
Note: Both the counselor and the individual counseled should retain a record of the counseling.
APD LC v1.04ES
Page 2 of 2
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A4856 DEVELOPMENTAL COUNSELING FORM

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Completed 19 July 2020

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