Schools face an unprecedent demand for mental health services. Student mental health problems can be addressed via a continuum of mental health evidence-based practices (EBPs) integrated within school-wide Positive Behavioral Interventions and Supports (PBIS). However, integrating mental health interventions with PBIS can be challenging. The purpose of this study is to examine the integration of mental health interventions with PBIS in a group of schools in Pennsylvania. We describe the extent to which schools implementing PBIS with fidelity were using mental health EBPs at tiers 2 and 3, examine recommendations about how to achieve further integration, and identify school professional needs for training and support. The study is based on a statewide sample of 48 K-8 schools. Members of the leadership team completed questionnaires and participated in qualitative interviews. Most schools had established advanced tiers of support and offered EBPs for externalizing behavior problems at tier 2. However, few schools reported offering mental health EBPs at tier 3, or interventions for internalizing problems. Qualitative analyses of interview transcripts revealed key recommendations regarding characteristics of interventions students should receive, who should provide the extra supports to students and the type of training that should be made available to school personnel and providers of tier 2 and tier 3 interventions. Participants indicated school mental health personnel did not receive adequate technical assistance to implement EBPs.