Developmental Counseling FORM For use this form, see FM 6-22; the proponent agency in TRADOC.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
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.
Part I - Administrative Data
Name (Last, First, MI)		Rank/Grade	Date of Counseling
Organization	Name and Title of Counselor
PART II - Background Information
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):                                            Event Oriented: Weekend Safety Briefing To: 1. Encourage safety awareness 2. Establish procedures for notifying the chain of command in the event of an accident 3. Ensure proper planning of travel time 4. Encourage Stewardship of the Army Profession 5. Encourage Ethical Leadership (Steward and Servant) and the decision making process.
Part III - Summary of Counseling Complete this section during or immediately subsequent to counseling.
Key Points of Discussion
Every Soldier has a responsibility to Steward the Army's profession. As a fundamental of leadership, this may require some form of servant leadership, meaning your actions should be taken for the "good of the group". Insubordination, unruly behavior, and lack of concern for safety and the law are indications of poor stewardship and an absence of leadership that can diminish the U.S. Army's reputation. Thus, your actions, whether on or off duty can effect the entire organization in either positive or negative ways. Utilize an ethical approach to decision making, while remaining true to yourself and your organization. For more about ethical leadership, visit  URL: http://usacac.army.mil/CAC2/MilitaryReview/Archives/English/MilitaryReview_20100930ER_art015.pdf and read ADP 6-22. Initial each to indicate your understanding: _____ SHARP -  If you need help, say something. If you witness something inappropriate, intervene. If you wish to report an incident of sexual assault, please contact the 7th ID SHARP hot line at (253) 389-8469. The line is open 24-hours a day, seven days a week and covers the JBLM Military Community. As always, you can report incidents to you Chain of Command or file a restricted report with the Unit SARC. _____ Suicide Awareness/Help - Seeking help is a sign of strength, not weakness. If you observe a suicidal ideation, utilize the "Ask, Care, Escort" technique to ensure the individual is safe. DO NOT Leave him or her unattended until professional help has been attained. For emergencies, call 911 or 253-967-1481. _____ Domestic Violence will not be tolerated. Family advocacy (253-967-5940), the Chaplin, and your chain of command are all at your disposal for help and advise. _____ Illegal substances - The Army has zero tolerance for the use, possession, or sale of illegal substances or abuse of prescription drugs. For a comprehensive list of    prohibited substances, visit URL: https://acsap.army.mil/public/laws/army.jsp or see AR 600-85.   _____ Maximize the use of the buddy system and take the time to understand the current threat conditions and current illegal trends in the area. Avoid spontaneous group gatherings or demonstrations. Stay vigilant and report any suspicious activity to the JBLM MPs or PROVOST Marshall @ 253-967-4357 _____ If you consume alcohol, do so in moderation. _____ Only swim in approved areas with a lifeguard present. _____ Do not patronize off limit establishments or any establishment that promotes, supports, or facilitates human trafficking, violence, or illegal substances. _____ Do not attempt to participate in activities that are clearly outside of your physical/mental capabilities or state of mind if affected by alcohol or medication. Use caution if you are going to mix alcohol and sporting events as the risk of injury is increased. _____ Practice safe sex. _____ Fire Safety - Check your smoke detectors in your home. When grilling or barbecuing, practice safe techniques to avoid burns to yourself, children or property. Are you planning extended travel outside JBLM area or more than a 250 mile radius from the local area?  YES NO If so, do you have an extended travel pass? N/A YES NO If leaving the country, complete a treat awareness brief from S2? YES  NO Note: you are not authorized to travel 250 miles until a DA Form 31 is processed.  (DA31 is required for all passes to include mileage pass) _____ When traveling, be sure to afford yourself adequate time for rest stops. Adjust your speed to the posted speed limit and weather conditions. _____ Check with you banking institution to ensure your debit/credit cards will work once you reach your destination to avoid delays in your return. _____ Do not drive after you have consumed alcoholic or mood altering medication. Do not ride in a vehicle if the operator is impaired in any way.  _____ Do not allow other Soldiers to operate vehicles or endanger themselves if you believe them to be impaired. If you are unable to resolve this situation yourself,                    inform the MPs and your chain of command immediately. _____ Ensure your vehicle has been inspected and is in safe running condition. This includes ensuring you comply with JBLM/State Laws regarding seasonal tires. _____ Do not wear your military uniform off base, except when traveling to and from your residence, unless there is an emergency. _____ If you find your self in a situation and need help, contact me as soon as it is safe to do so. My numbers is (253-000-0000). If I am not available, utilize your alert roster, which will provide you any number for your Chain of Command, CQ 253-000-0000, Staff Duty 253-000-0000, etc.
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, 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):  1. Soldier will comply with the contents of this counseling and all verbal elements of the safety briefing. 2. Soldier will ensure they have their leader contact card and my phone number on their person at all times during the pass period. 3. Soldier agrees to implement the following actions: 4. If he or she encounter any problems they are to contact me immediately 5. If I am unavailable they are to contact {phone # of next higher Soldier in NCO Support Channel or Chain of Command} 6. If the secondary POC is not available, the Soldiers will utilize the Alert roster to contact the Chain of Command. If no response from the chain of command, he or she will immediately contact the unit staff duty office (CQ 253-000-0000 or Staff Duty 253-927-0000).

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): 1. Ensure Soldier understands the contents of the counseling 2. Ensure Soldier has a unit leader card and/or phone numbers of key leaders in their immediate possession. 3. File copy of the counseling 4. Assist Soldier as required 5. Continue mentoring and coaching the Soldier to reiterate the importance of Ethical Leadership and Stewarding the Army Profession. Signature of Counselor:  _________________________________________  Date:  _____________________

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): Counselor: ___________________    Individual Counseled:  __________________  Date of Assessment:  __________

Note:  Both the counselor and the individual counseled should retain a record of the counseling.

DA FORM 4856, AUG 2010