<p>Given the expanding mental health needs of youth, schools have worked to increase mental health services that are available to address those needs. Despite the expansion of these supports, a gap exists between the availability of school mental health resources and the youth who are willing to participate in services. The current study engaged middle and high school youth to better understand their perspectives and experiences utilizing school mental health groups and related services. Forty-five youth in grades 6–12 from 12 schools in an urban Midwestern school district participated in focus groups to examine how youth perceive and experience school-based mental health services, as well as to examine barriers and facilitators for youth accessing and sustaining participation in school-based mental health services. Qualitative data were analyzed using thematic analysis. The relationships youth have with educators and school mental health providers and the climate and culture of the school towards mental health services were the most frequently cited reasons for youth accessing mental health supports in schools. Confidentiality, privacy concerns, and confusion around the mental health services being offered at school were the most prominent reasons youth did not participate in mental health services. Our findings suggest improvements to how mental health services are advertised and introduced to youth in schools in order to increase utilization, the need for youth to build trusting relationships with educators and school mental health providers who are delivering services, and the necessity of ensuring students’ feel that they have privacy and confidentiality in school settings.</p>