DEVELOPMENTAL COUNSELING FORM
For use of this form, see FM 22-100; 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 and E.O. 9397 (SSN)
To assist leaders in conducting and recording counseling data pertaining to subordinates.
For subordinate leader development IAW FM 22-100. Leaders should use this form as necessary.
Disclosure is voluntary.
PART I - ADMINISTRATIVE DATA
Name (Last, First, MI)
Organization
Rank / Grade
Social Security No.
Date of Counseling
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 leaders facts and observations prior to the counseling)
MID-TOUR LEAVE
TO DISCUSS WITH THE SOLDIER AND GAIN HIS/HER AWARENESS OF THEIR RESPONSIBILITIES WHEN ON
AUTHORIZED LEAVE.
FURTHERMORE TO ADVISE PERSONNEL GOING ON LEAVE CONCERNING SAFETY ISSUES
PART III – SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to counseling.
Key Points of Discussion:
YOU ARE GOING ON AUTHORIZED LEAVE, IAW AR 600-8-10. LEAVE FOR US SERVICE MEMBERS ON ACTIVE DUTY
IS GOVERNED BY SECTION 701, 702, 703, 704, 705, 708 AND 876A, TITLE 10 OF US LAW.
1. WHILE ON LEAVE, YOU ARE STILL A SOLDIER IN THE US ARMY, SUBJECT TO RECALL BY THE COMMANDER.
FURTHERMORE, ALL REGULATIONS GOVERNING THE CONDUCT OF MILITARY PERSONNEL APPLY.
2. LEAVE IS MANAGED BY INDIVIDUAL COMPANIES, AND THUS THE DAYS APPROVED FOR LEAVE ARE SUBJECT
TO APPROVAL BY THE COMPANY COMMANDER. FOR REASONS OF MILITARY NECESSITY, AND IN ORDER TO
COMPLY WITH 2ID PERSONNEL READINESS REQUIREMENTS.
3. IT IS THE SOLDIERS RESPONSIBILITY TO ENSURE HE/SHE RETURNS FROM LEAVE AND SIGNS INTO THE
COMPANY NLT MIDNIGHT ON THE DATE LEAVE EXPIRES. FAILURE TO RETURN ON TIME FROM LEAVE MAY
PLACE YOU IN THE STATUS OF ABSENT WITHOUT LEAVE(AWOL). THIS IS IN VIOLATION OF ARTICLE 86,
UCMJ(AWOL), AND ARTICLE 92, UCMJ, FAILURE TO OBEY ORDER OR REGULATION. YOU MAY BE SUBJECT TO
ADVERSE DISCIPLINARY ACTION UNDER THE UCMJ. BY COMPANY POLICY, YOU ARE REQUIRED TO HAVE A
RETURN TICKET PRIOR TO GOING ON LEAVE.
THE FOLLOWING REASONS DO NOT REPRESENT A LEGITIMATE EXCUSE FOR FAILING TO RETURN FROM LEAVE,
AND WILL NOT BE ACCEPTED.
A. MISSING YOUR RETURN AIRPLANE FLIGHT.
B. FAILURE TO COMMUNICATE WITH YOUR CHAIN OF COMMAND WHEN A PROBLEM CONCERNING YOUR
RETURN ARISES.
C. FAILING TO HAVE SUFFICIENT FUNDS TO COVER THE RETURN TRIP (INCLUDING GETTING ANOTHER TICKET IF
NECESSARY), EITHER THE FLIGHT OR THE FARE FROM THE AIRPORT.
D. DEPENDING ON AND FAILING TO GET A SPACE AVAILABLE FLIGHT FOR THE RETURN TO KOREA.
4. BE ADVISED THAT PROBLEMS WITH YOUR AIRLINE TICKET REPRESENT A CIVIL MATTER BETWEEN YOU AND
THE AIRLINE AND THE ARMY IS NOT REQUIRED TO ADJUST
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, JUN 1999
EDITION OF JUN 85 IS OBSOLETE
USAPA V1.00
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. YOU WILL HAVE A TWO-WAY TICKET THAT COVERS YOUR RETURN TO STATION, PRIOR TO DEPARTING ON LEAVE.
2. YOU WILL SIGN OUT AT THE EOC ON THE DAY YOUR LEAVE STARTS.
3. YOU WILL BE ABLE TO BE CONTACTED THROUGH THE TELEPHONE INFORMATION ON YOUR LEAVE FORM.
SAFETY BRIEFING:
A. ALCOHOL: Drinking alcohol remains a privilege which should be enjoyed in moderation and in the company of a buddy who will
assist the individual. A person drinking must never drive a vehicle and put their safety and those of others at risk. Alcohol incidents in
which the individual on leave are involved in will be dealt with IAW Army Regulations and the applicable 2ID, Battalion and company
policy letters.
B. DRIVING: Individuals on leave should practice safe driving and be advised not to attempt to drive too many hours, especially at night
without rest. Leave is a pleasurable time, but one must try not to do too many things and see too many friends and family members if the
effort puts one's safety at risk.
C. Food poisoning, sunburn, transmission of diseases are all threats that may occur during leave and common sense precautions apply.
D. WATER SAFETY: concerns apply to personnel on leave. Never mix alcohol with water activities and never conduct water sports
activities alone. Know your limits and don't put yourself at risk.
E. Common sense precautions against unsafe sex must also be taken by personnel on leave. Be advised that all Army Regulations apply
and it is Army policy to discharge personnel who contract AIDS and certain other sexually transmitted diseases (STD's).
F. The use of controlled substances (i.e. illegal drugs) is prohibited by law and Army regulations. Army regulations authorize the testing of
Soldiers upon return from leave.
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
Individual counseled remarks:
 disagree with the information above
Signature of Individual Counseled: ______________________________________________Date: ____________________
Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action.)
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.
REVERSE, DA FORM 4856, JUN 1999