The Center for Collegiate Mental Health (CCMH) 2021 Annual Report describes 153,233 unique college students, nationally and internationally, seeking mental health treatment; 4,043 clinicians; and more than 1,135,520 appointments from the 2020-2021 academic year. This is the 13th year the report has been produced. This year's report specifically examined the relationship between counselor caseloads (Clinical Load Index (CLI) scores) and the amount of treatment received by students with critical and key needs (e.g., students with suicidality, recent self-harm, sexual assault survivors, and students with a registered disability). Also captured in the report are the ongoing mental health trends among college and university counseling centers. Several mental health trends shifted during 2020-2021, likely a consequence of the impacts from the COVID-19 pandemic. Findings demonstrated students with all presenting concerns, on average, received less treatment at high CLI centers, including clients with recent serious suicidal ideation and self-injury, histories of sexual assault and trauma, transgender identity, registered disability, first-generation identity, and various racial/ethnic identities. The report concludes that the increasing demand for services in college counseling centers over the last two decades, coupled with the lack of equivalent funding to increase treatment capacity, has led to negative consequences for counseling centers, including pending questions about the effect on the counselors providing services. [Additional support for this research comes from the collaborative efforts of over 600 university and college counseling centers; Association for University and College Counseling Center Directors (AUCCCD); Titanium Software, Inc.; and the Penn State University Counseling and Psychological Services. For the 2020 report, see ED610604.]