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 112a (Wrongful use, possession of controlled substances) of the Uniform Code Of Military Justice in that on
or about(date) at (location) you wrongfully (used, possessed, distributed)_________________(what happened? Describe in detail).
                                                  PART III - SUMMARY OF COUNSELING
                       Complete this section during or immediately subsequent to the counseling

Key Points of Discussion:

Wrongful (use, possession, distribution) of ____________ is a crime and it is unacceptable behavior that will not be
tolerated. If found guilty of this offense, the maximum punishment is ______________________. Your reckless behavior
jeopardised your personal safety and the safety of those around you as well as the effectiveness of our unit to
successfully accomplish the missions at hand. (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.   
                                                                                  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
Download and make changes to Counseling for violation of Article 112a
(Wrongful use, possession of controlled substance ) of the UCMJ. Requires Pure edge viewer
Article 112a Wrongful use, possession of controlled substances: Any member of the armed forces who, wrongfully uses, possess,
manufactures, distributes, or imports any illegal or controlled substance; may be punished under article 112a.
(opium, heroin, cocaine,
amphetamine, LSD, marijuana, and any other illegal substance or prescription drug)
Initial Counseling                                                             Monthly Counseling

Over Weight Counseling                                                APFT  PT Test Failure

WLC Counseling                                                              Accessory after the fact

Conspiracy                                                                         Misuse of Government Credit Card

Fraudulent enlistment/separation                                 Absent without leave AWOL

Missing movement                                                           Bar To Reenlist

Disrespect toward a Officer                                           Civilian Education

Assaulting/disobeying an Officer                                   Debt Obligations

Disrespect toward an NCO/Warrant Officer               Motorcycle Safety

Lost/damaged military property                                     Pregnancy

Drunk on duty

Use/possession of a controlled substance




Issuing worthless checks

Lost Military ID Card

Family Care Plan

Separation from the Military

Flag actions
Counseling Statement Examples
Custom Search
Custom Search