| DEVELOPMENTAL COUNSELING FORM
For use this form see FM 22-100
| DATA REQUIRED BY THE PRIVACY ACT OF 1974
|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: For subordinate leader development IAW FM 22-100 leaders should use this form as necessary
DISCLOSURE: Disclosure is voluntary
| PART I - ADMINISTRATIVE DATA
|Name (Last, First, MI)
||Social Security No.
||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 leaders facts
and observations prior to the counseling)
Event-Oriented: Violation of article 81 (Conspiracy) of the Uniform Code Of Military Justice in that on or about (date) at (location) you Conspired
with others to commit (type of offense).
| PART III - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to the counseling
Key Points of Discussion:
Conspiring with others to commit a crime is, itself, a crime. If found guilty of this offense the maximum punishment
is______________________.As a member of the United States Military you are expected to uphold the Honor and
commitment of the Soldiers that have Honorably served our country before you. In committing such misconduct you have
brought discredit upon The United States Army, this Unit, and Yourself. Further misconduct of any type by you will not be
tolerated. (I am recommending that the commander impose nonjuducial punishment for your misconduct) OR (You will
receive corrective training as outlined in the plan of action).
You are here by notified that if this type of conduct continues, actions may be initiated under the Uniform Code of Military
Justice to separate you from the Army prior to your scheduled ETS Date IAW AR 635-200. If you are involuntary
separated, you could receive an Honorable Discharge, a General (Under Honorable Conditions) Discharge, or a Under
Other Than Honorable Conditions Discharge. If you receive a discharge Under Other Than Honorable Conditions, you will
be ineligible for reenlistment and for most benefits, including payments of accrued leave, transitional benefits, the
Montgomery GI Bill, VA benefits, and You may also face difficulty in obtaining civilian employment.
| OTHER INSTRUCTIONS
This form will be destroyed upon reassignment (other than rehabilitative transfers), separations at ETS, or upon retirement. For separation requirements
and notification of loss of benefits/consequenses see local directives and AR 635-200
|Article 81 Conspiracy: Any person who conspires with others to commit a criminal offense, will be punished under article 81.
THIS IS NOT A GOVERNMENT SPONSORED WEB SITE
|Counseling Statement Examples