Rural Appalachia encompasses a region of the United States represented by unique cultural strengths and systemic challenges. To meet their students' career and college needs, school counselors working in rural Appalachia must understand the cultural nuances of the region. Consensual qualitative research (CQR) methodology revealed five domains and 20 categories describing how rural Appalachian high school counselors address career and college readiness. We provide implications for career and college programming for use by high school counselors in rural Appalachia.