Sunday, February 5, 2012

Initial Counseling for Family Care Plan

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Developmental Counseling FORM

For use this form, see FM 6-22; the proponent agency in TRADOC.
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)


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 leader’s facts and observations prior to the counseling):

            •  Discuss Initial Counseling for Family Care Plan IAW AR 600-20
            •  Ensure that the soldier understands the importance of a valid Family Care Plan

Part III - Summary of Counseling
Complete this section during or immediately subsequent to counseling.
Key Points of Discussion

It has come to my attention that you are currently a: (inicated by check mark)
                _____ single parent
                _____ member of a dual military couple 

As a result you are required to maintain a Family Care Plan.  During this counseling session I will inform you of the items you are required to maintain in your Family Care Plan.  You will have 30 days from today’s date to present your completed Family Care Plan to me.  Failure to complete your Family Care Plan could result in a bar to reenlistment or separation from the military.  Once your Family Care Plan has been validated you are required to update your Family Care Plan at a minimum:
                •  Once a year during your birth month
                •  If any changes occur that make your plan invalid
                •  As otherwise directed by the chain of command

You must also understand that the command may require you to execute your Family Care Plan for testing of validity (for example: during exercises, alerts, and other unit activities).  The command may periodically call your providers or guardians to ensure that they understand their responsibilities.

You are required to maintain the following forms in your Family Care Plan Packet:

1.  _____DA Form 5304-R (Family Care Plan Counseling) (Signed by the Commander and Spouse’s Commander when dual military)
2.  _____DA Form 5305-R (Family Care Plan) (Approved by Commander/Spouse’s Commander when dual military)
3.  _____DA Form 5841-R (Special Power of Attorney for Guardianship) (Copy)
4.  _____DA Form 5840-R (Certificate of Acceptance for Guardianship and Escort) (Original)
5.  _____DD Form 1172 (ID Card Application – one per dependent)
6.  _____DD Form 2558 (Allotment Form or other proof of financial support)
7.  _____Letter of Instruction to Guardian(s) and Escort (Copy)
8.  _____Will (Optional)     
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): 

• Soldier stated that he understood the contents of the counseling.  Soldier was directed to return to me no later than DATE for the final review and validation of the Family Care Plan.  I also explained that should the soldier need more time to complete the Family Care Plan they could request and extension in writing explaining why the extension is required.

•  information purposes only: reviewed with the soldier that failure to maintain a Family Care Plan could result in separation from the military.  In addition reviewed requirements AR 635-200 Para 1-18(a) and notification of possible separation.     

•  Requested that soldier list any areas that may currently be a problem:

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):

•  Conduct review/assessment with soldier
•  Conduct review of notification of separation (information only)     

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):

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

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