Name
(Last, First, MI)
Rank/Grade Date of Counseling
Organization Name and Title of Counselor
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 v1.03ES
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C IV
Utah
Army
National
Guard
-
Recruiting
and
BN
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.)
This counseling clearly outlines and defines your requirements with an 18 series REP 63
(aka 18X) contract with the 19th Special Forces Group (A) in Utah.
Including your recruiter, there at 13 individuals that will be working to bring you into 19th Group. All are professional Noncommissioned Officer, Warrant
Officers, and Civilians. By signing, you are stating that you have made a firm commitment to process with our team, to be professional, and to be timely with the
processing steps.
This statement of understanding is required in order to secure a position and be offered the Special Forces Contract as an Enlistment Option. By signing, I state that I
agree to the following conditions as outlined below:
o I am intentional about my decision to enlist into the 19th Special Forces Group (A) in Utah. I understand that being a member of the Special Forces unit, I may be
required to attend additional schooling and training which exceeds that of a traditional Army National Guard Soldier. I understand that I will be expected to dedicate
more time to the Utah Army National Guard and the 19th Special Forces Group (A) in order to accomplish my mission, schooling and training requirements.
o I have no
hesitations or reservation about committing to the Special Forces Training Pipeline.
o I have the support of my spouse, loved ones, and/or family support group to enlist with the REP 63 option.
o I understand that I must enlist with an Army Feeder MOS as part of the REP 63 Contract. 11B Infantry will serve as the feeder MOS, no other MOS is authorized.
o I understand that 11B/18 Series are combat MOS's and that I am extremely likely to deploy to a combat zone after completion of training.
o I understand that there are no 11B positions available to me in the State of Utah. If I am unable to complete the Special Forces Training Pipeline for any reason, I
understand that I will be retained on Initial Active Duty Training (IADT) to re-class to a different MOS at the needs of the 19th. I may also be re-assigned to a
new unit at the needs of the Utah Army National Guard IF a support position cannot be secured within the 19th Special Forces Group (A).
o If qualified and I deny enlistment with the REP 63 contract offered, I understand that I will never again be offered said contract. I also understand that if I
voluntarily withdraw at any time during IADT prior to starting SFAS, that I will never again be offered an SF (REP 63) contract from the 19th Special Forces
Group (A). Special circumstances leading to the inability to complete enlistment or training will be considered on a case by case bases.
o If I am a Utah resident, I will coordinate with my recruiter to obtain a Chapter 5 SFAS Physical at the Utah Medical Detachment after enlistment.
o If I reside out of state, I understand that the Utah Army National Guard Recruiting Command will only pay for 1, round trip ticket from my home of record to Utah
for the purposes of enlistment, baring any special circumstances.
o I understand that I will have post enlistment requirements that I must complete before shipping to Basic Combat Training. The requirements are:
- Pass the Occupational Physical Assessment Test (OPAT) - Completed in Utah during enlistment process
- Enroll my spouse and/or dependents in DEERS (if applicable)
- Complete a Chapter 5 SFAS Physical (Utah residents only)
- Obtain a Military ID (Common Access Card)
SSG Marty Grant - RRNCO
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.)
REVERSE, 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.
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o Keep the Recruit Sustainment Program (RSP) of assignment apprised of ANY changes to your status. This includes but is not limited to the following:
- Injury
- Severe illness
- Arrest or criminal charges (including traffic tickets)
- Dependency Changes (marriage, divorce, children, death of immediate family member or dependent, etc.)
- Change of Residence or Home of Record
o Complete post enlistment requirements.
o In addition to updating the RSP of any changes, you will also contact your Recruiter for additional support and administrative tracking.
Special Forces MOS Request:
1st MOS Choice: _______________________ _________________
2nd MOS Choice: _______________________ _________________
Language Options: ______________ ______
Do you speak any other language?_______ _ Language:__________ __________
o
Consistently
communicate
with
the
Soldier
o Coordinate RSP Drill (if out of state)
o Address any concerns or questions in a prompt manner
o SF Recruiter Contact Information: ______________________ ___________________ _______________________________________
SSG Marty Grant
801-660-7055
marty.a.grant.mil@mail.mil
click to sign
signature
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