| PART II - BACKGROUND INFORMATION | 
| Purpose of Counseling Performance Counseling: Initial Counseling 
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| PART III - SUMMARY OF COUNSELING Complete this section during or immediately subsequent to counseling. | 
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| 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| DA FORM 4856, MAR 2006 EDITION OF JUN 99 IS OBSOLETE | 
| Plan of Action: 
 
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| 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: _ _7 Jan 2018_ _ | 
| Leader Responsibilities: (Leader's responsibilities in implementing the plan of action) 
 Signature of Counselor: _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _7 Jan 2018_ _ | 
| 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: _ _ _ _ _ _ _ | 
| Note: Both the counselor and the individual counseled should retain a record of the counseling. | 
| DA FORM 4856 (Reverse) | 


