Army Counseling Form
Name of the Person Counseled
First Name
Middle Name
Last Name
Rank
Organization
Date of Counseling
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Counselor Name
First Name
Last Name
Title
Purpose of Counseling
Example: Performance/Professional or Event-Oriented counseling, etc.
Key Points of Discussion
Plan of Action
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 specified time line for implementation and assessment
The person counseled agrees/disagrees and gives remark if applicable.
I, counseled person, agree with the information above
I, counseled person, disagree with the information above.
Counseled Person's Remarks
Please List Leader's Responsibilities
Assessment of Plan of Action
If the plan of action needs to achieve the desired results, fill this part. This part should be completed by both the leader and the individual counseled and provide useful information for follow-up counseling.
Record of Counseling
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Both the counselor and the individual counseled should retain a record of the counseling.
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of
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Counseled Person
Signature of Counselor
Submit
Should be Empty: