This paper describes a year of efforts to establish psychiatry residents into a Coordinated School Care Initiative (CSCI) being enacted in several high-risk urban schools located in the South. A four-phase model of school site selection is presented and a child referral pathway is described. This is followed by a case study of two similar high-need elementary schools “A” and “B”. Each school was served by a Caucasian 5th year child psychiatry resident. Four factors associated with the relative success of School “A” versus School “B” were delineated: administrator buy-in and active support; advance logistical preparation by the school; a previously established therapist to serve as the referral agent, and low staff turn-over. In contrast, School “B” also suffered with exceptionally low parent involvement. School “B” staff were frequently observed to administer inconsistent and harsh disciplinary practices. These latter factors were associated with a particularly negative school climate. In keeping with the Plan, Do, Check, Act model, lessons learned were articulated. As a result, the Year Two focus will include concerted efforts to move from a co-located to an integrated experience among all members of the child’s environment: administrators, teachers, school nurses, therapists, and parents. This will bring the CSCI in line with the Coordinated School Health Model articulated by the CDC.