Long history of impulsive behavior and emotional dysregulation in the context of in utero substance exposure, prematurity, and repeated disruption of parental caregiver relationships. The current history suggests that he functioned fairly well over the last couple of years with relatively low level mental health services – highly experienced foster parent, individual therapy every 1-2 weeks, and occasional pharmacology. However, he began using cannabis more regularly and was unable to stop use when limits were set, leading to disruption of his foster placement. He has had significant dysregulation in a shelter and then crisis center setting since losing his foster home placement, including threatening peers, brandishing makeshift weapons, destroying property, and then finally physically attacking a peer (we do not have information about what provoked this) leading to his being sent to the ED. He has been consistently calm and polite here, though withdrawn, without evidence of clear active mood, psychotic, or anxiety disorder that would indicate a need for psychiatric hospitalization.