DEVELOPMENTAL COUNSELING FORM For use this form see FM 22-100
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DATA REQUIRED BY THE PRIVACY ACT OF 1974
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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
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PART I - ADMINISTRATIVE DATA
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Name (Last, First, MI)
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Rank/Grade
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Social Security No.
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Date of Counseling
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Organization
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Name and Title of Counselor
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PART II - BACKGROUND INFORMATION
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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 123a (Making, drawing, or uttering checks, draft, or order without sufficient funds) of the Uniform Code Of Military Justice in that on or about(date) at (location) you issued a check to_____________ in the amount of $________ and (failed to maintain sufficient funds? What happened?).
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PART III - SUMMARY OF COUNSELING Complete this section during or immediately subsequent to the counseling
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Key Points of Discussion:
Issuing a worthless check is a crime under both the Uniform Code of Military Justice and________State law. If found guilty of this offense, the maximum punishment is______________________. As a member of the United States Military you are expected to conduct yourself in a professional manner and abide by the moral values that make our military the best in the world. Your misconduct has been detrimental to the morale and discipline of this unit and it has resulted in the loss of confidence in you by the members of this organization. (I am recommending that the commander impose nonjudicial 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.
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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
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Army Counseling, Article 123a Making, drawing, check, draft or order without sufficient funds: Any member of the armed forces who, knowingly issues a check, draft , or any other form of payment to any person or business, with intent to defraud ; may be punished under article 123a.
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Use this Counseling Example when your Soldier issues a check with insufficient funds available. As a supervisor you are likely to receive letters
from merchants requesting that your Soldier pay for goods and services after a check has bounced due to there not being enough money in the
Soldier's bank account. You must counsel your Soldier upon notification and encourage your Soldier to make good on his or her promise to pay
the money owed. You as a leader also have the responsibility to refer your Soldier to financial classes. You may recommend your Soldier for
punishment under the UCMJ If this becomes habitual behavior but always try to help the Soldier first. Got Questions or Comments?
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