School social workers frequently serve as the primary mental health providers to youths with mental health problems. Although school social workers play a primary role in care, many students also receive outside counseling services. Previous research has not examined whether practice approaches differ when considering mental health practice with students for whom school social workers are the primary providers versus those who receive outside counseling. This article uses respondents from the 2008 National School Social Work Survey who worked primarily with students with either emotional or behavioral problems to examine whether practice approaches differed between groups of school social workers for whom all or most of their students received outside counseling and those for whom few of their students received these services. Results demonstrate that the groups were different with respect to practice choices, as school social workers who worked with students receiving outside counseling reported greater engagement at all levels of the ecological system except for the school domain and the practice approach of group counseling. Both groups cited work with teachers as the least used aspect of school social work practice. Implications for the future of school social work research, practice, and policy are discussed.