Family Care Plan Counseling Checklist printable pdf download

FAMILY CARE PLAN COUNSELING CHECKLIST

For use of this form, see AR 600-20; the proponent agency is DCSPER

Careful planning is required to ensure adequate care of dependent family members while performing required military duties.

Pregnant soldiers, single parents, and dual-military couples with dependent family members will be counseled in accordance with

AR 600-20. The soldier and the commanding officer (or designated representative) will initial each item on the checklist.

PART I - ACTIVE AND RESERVE COMPONENT

SOLDIER

COMMANDER

A. I am receiving Family Care Plan counseling by my commander (or designated representative)

because my current family status is:

1. A pregnant soldier who:

a. Has no spouse; is divorced; widowed, or separated; or is residing without her spouse.

Is married to another service member of AC or RC of any service (Army, Air Force, Navy, Marines,

Coast Guard).

2. A soldier who has no spouse; is divorced, widowed, or separated or is residing apart from his/her spouse;

who has joint or full legal and physical custody of one or more dependent family members under age 19 or who

has adult dependent family members incapable of self-care regardless of age.

3. A soldier who is divorced (not remarried) and who has liberal or extended visitation rights by court decree

which would allow dependent family members to be solely in the soldier's care in excess of 30 consecutive

days.

4. A soldier whose spouse is incapable of self-care or is otherwise physically, mentally, or emotionally disabled

so as to require special care or assistance.

5. A soldier categorized as half of a dual-military couple of the AC or RC of any service (Army, Air Force,

Navy, Marines, Coast Guard) who has joint or full legal custody of one or more dependent family members

under age 19 or who has adult dependent family members incapable of self-care regardless of age.

B. I understand that I must arrange for the care of my dependent family member(s) so as to be:

(1) Available for duty when and where the needs of the Army dictate; (2) Able to perform my assigned military

duties without interference of family responsibilities.

C. I have been counseled on the importance of:

Selecting qualified, reliable, and stable guardians

(temporary and long-term),

whom I would have no

reservations about entrusting the sole care of my dependent family members, and who are both capable and

willing to care for them in my absence.

2. Providing maximum information to guardians on the full extent of their responsibilities and on procedures for

gaining access to military/civilian facilities, services, entitlements and benefits on behalf of my dependent family

member(s).

Providing all necessary documentation and financial support so that the designated guardians have

everything necessary to act in that capacity.

I understand that designated guardians must be able to assume responsibility for my dependent family

member(s)

during any periods of absence to include: during duty hours, alerts, field duty, roster duty, TDY,

deployments, AT, MUTAs, ADT, or in the event of hospitalization, or other periods of absence for military duty,

emergencies or unexpected circumstances.

I understand that I am fully responsible for making all necessary arrangements (housing, educational, legal,

transportation, financial, religious, special, etc.) to ensure a smooth, rapid turnover of dependent family member

care responsibilities in case the plan is implemented.

I understand that I must initiate legal documentation such as the power of attorney for guardianship (DA Form

5841-R) which will authorize guardian(s) to act in loco parentis; to perform any and all acts as fully to all intents

and purposes as I might or could if personally present; to authorize for the care and treatment of my dependent

family member(s) regardless of whether on an emergency basis, or for routine care, including all major surgery

deemed necessary by a duly licensed staff physician at any military or civilian hospital; to register my child(ren) in

school, and to grant or to withhold permissions as my attorney shall deem appropriate.

I understand that designated guardians must submit notarized certificates of acceptance (DA Form 5840-R),

agreeing to accept full responsibility for my dependent family member(s); attesting that they have received all

necessary and essential documents; and attesting to the fact that they have been provided information on how to

gain access to military/civilian facilities, services, entitlements and benefits on behalf of my dependent family

member(s).

H. I understand that I must maintain in my Family Care Plan, a DD Form 1172 for each dependent family member to

ensure the issue/renewal of Uniformed Services Identification Cards in my absence.

I understand that my Family Care Plan must be updated and recertified by my commander at least annually

(more often if required by my commander or mission of my unit), or in the event of any change in my family status,

guardians, legal custody, duty station, etc.

I understand that it is strongly encouraged (though not mandatory) that I ensure that I have an updated will

which specifies my desires concerning custody of my dependent family member(s) in the event of my death.

K. I understand that there are voluntary and involuntary procedures for my separation from military service when

my parental responsibilities interfere with the performance of my military duties.

DA FORM 5304-R, MAR 92

DA FORM 5304-R, SEP 89 IS OBSOLETE

USAPPC V1.00

Family Care Plan Counseling Checklist

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