This article presents the results of a study documenting the complex mental health needs of 95 inner city youth consecutively referred for mental health care. An ecological perspective of mental health need guides the presentation of issues and stressors that occur at the level of the individual child; within the family, school, and community; and within the larger service system context. Findings related to the intersection between child mental health needs and trauma exposure are described. In addition, the level of service involvement of these children is presented. Results reveal low rates of ongoing service involvement despite multiple, complex presenting mental health issues and significant levels of trauma exposure. Implications for urban service delivery and recommendations to prepare service providers are drawn.