| PART II - BACKGROUND INFORMATION | 
| Purpose of Counseling: 
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| PART III - SUMMARY OF COUNSELING Complete this section during or immediately subsequent to counseling. | 
| Key Points of Discussion: 
 | 
| 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-E | 
| Plan of Action: 
 | 
| 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) 
 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. | 
|   DA FORM 4856-E (Reverse)                        | 


