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DA Form 4856 - Missed Appointment


  Purpose of Counseling

    Missed Appointment

Complete this section during or immediately subsequent to counseling.

Specialist Sullivan, on 4 April 15, you were identified as having missed a scheduled dental appointment.

Soldiers have access to a variety of professional care and guidance and are free to make appointments for these services but, when an appointment is made, it is the Soldier's responsibility to either cancel the appointment in a timely manner or show up for these obligations.

If I make an appointment for you, I will remind you weekly of the upcoming appointment however it is still ultimately your responsibility to make the appointment once notified.

You must inform me if you cancel an appointment to prevent an erroneous report of a missed appointment. If you cancel an appointment, you will write a short MFR stating the date and time of the specified appointment, the date and time it was cancelled, and with whom you spoke. The MFR will be kept at the section level.

Appointments must be cancelled through proper channels. Going directly to the clinic and canceling the appointment may not suffice.

Soldiers must cancel appointments regardless of the reason for missing the appointment. Going TDY or on leave or being deployed does not relieve you of that responsibility.

In accordance with unit policy, Soldiers who miss appointments will face the following actions:

First missed appointment: written counseling statement by the Commander or 1SG

Second missed appointment: written counseling statement by the Commander or 1SG, and corrective training

Third missed appointment: summarized Article 15 or recommendation to supervisor for further action

Fourth missed appointment: Company Grade Article 15 or recommendation to supervisor for further action

This counseling statement has been furnished to you, not as a punitive measure under the provisions of article 15, UCMJ, but as an administrative measure to stress that continued behavior of the same or a similar nature may result in initiation of action separating you from the U.S. Army under the provisions of Chapter (5) (8) (11) (13) (14) , AR 635-200. Such action may result in either an Honorable Discharge, General Discharge, or an Other Than Honorable (OTH) Discharge. If you receive a General or an OTH Discharge, this could result in the possible loss of some or all Veterans Benefits and substantial prejudice in obtaining civilian employment. In addition, if you have contributed money to the Montgomery G.I. Bill and you are released from active duty with a less than Honorable Discharge, you will not be eligible to receive money for educational purposes and any money already contributed for educational purposes is nonrefundable and may be forfeited.

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, JUL 2014                         EDITION OF JUN 2011 IS OBSOLETE

  Plan of Action:

Making an appointment is the same as guaranteeing you will be somewhere at the agreed upon time. Just as you expect a provider to be there as scheduled, the provider expects you to be there as well. The dental office supports hundreds of members a day and works hard to keep the process of seeing Soldiers flowing smoothly. Missing an appointment interrupts that process and creates unnecessary additional work for schedulers, providers, and staff. Our goal is to support the organization that supports us by meeting all appointments.

Although I can understand your missing an appointment because of recent distractions, there is no valid excuse for missing an appointment. We must find a way to make sure you don't miss future appointments. People use a variety of methods but they all share one thing in common: they all realize, at the moment they make the appointment, that they have made a promise to be present at a certain time and place and must find a way to make sure they meet their obligation. Some people have established methods that they use over and over such as writing the appointment down in an appointment book and reviewing it daily. Others write it down on a sticky note and put it somewhere where they will see it every day to remind them of the impending appointment. I will not dictate the method you use because our goal is to make sure you meet all future appointments and the method I suggest may not work for you. You must choose a method that works for you and ensure you make all future appointmets because further missed appointments will result in more severe action and affect your career.

  Session Closing: (The leader summarizes the key points of the session and checks to ensure 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: : (Leaderís responsibilities in implementing the plan of action)

I will ensure that our leadership is aware of this counseling and will provide guidance and assistance whenever you request it or need it.


Signature of Counselor: ____________________________________ Date: ________

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)

SPC Sullivan has not missed any appointments since his initial counseling and has developed a method to ensure that he does not miss any in the future. As a military professional, he realizes the importance of integrity and personal responsibility to the unit and the Army.

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, JUL 2014                    

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