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American Indian (AI) youth experience significant mental health disparities. The majority of AI youth live in urban areas, yet urban AI youth are underserved and unstudied. This manuscript describes a qualitative study of community mental health needs in an urban population of AI youth, conducted as part of the planning process for a system of care (SOC). Participants included 107 urban AI youth and families that participated in one of 16 focus groups assessing mental health needs and services. Forty-one percent of participants were youth or young adults. Data were coded and analyzed using qualitative software and then further analyzed and interpreted in partnership with a community research workgroup. Results indicated various community characteristics, mental health and wellness needs, and service system needs relevant to developing a system of care in this community. Key community, cultural, and social processes also emerged, reinforcing the importance of broader system changes to promote a sustainable SOC. These systems/policy changes are reviewed in the context of previous literature proposing necessary systems change to support behavioral health care in AI communities as well as to ensure that SOC implementation is consistent with core values and philosophy across all communities.