Purpose: A chasm exists between the expanding mental health needs of school-aged youth and the school resources available to address them. Education agencies must efficiently allocate their limited resources by adopting innovative public health models. The need for these effective approaches is acute in rural regions, where resources tend to be scarce. This mixed-methods study of school superintendents illuminates key opportunities to optimize access to care for students struggling with mental health needs in rural communities. Method: Superintendents serving rural California school districts were targeted for a web-based, mixed response-type, 53-item survey designed to examine their perceptions across three school mental health-related categories: (a) strengths and gaps in community ethos and district infrastructure, (b) school personnel groups' knowledge and skills, and (c) predominant barriers. Of the targeted respondents, 16.7% completed the survey (N = 62). Quantitative data were analyzed using a series of descriptive analyses and paired-sample "t" tests. Qualitative data were analyzed using a constant comparative method with an open-coding approach. Findings and Implications: Budget constraints and access to trained school-based and community-based mental health personnel are the most frequently cited barriers to addressing mental health in schools. Knowledge and skills related to mental health are perceived to be more pronounced in district and school leadership than in other personnel groups, including staff typically responsible for providing mental health services, such as school psychologists. Our findings suggest a need to improve superintendent knowledge of innovative public health models for delivering mental health services within the constraints of rural school district settings.