Name (Last, First, MI) Organization PART I - ADMINISTRATIVE DATA Rank/Grade Date of Counseling Name and Title of Counselor PART II - BACKGROUND INFORMATION Purpose of Counseling: (Leader states the reason for the counseling, e.g.. 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..
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