This study analyzed family influences on treatment refusal in school-linked mental health services (SLMHS). Specifically, it assessed whether levels of family cohesion, conflict, and organization were related to whether a family refused to initiate recommended treatment. Children (N = 133) referred for emotional and behavioral problems and their families participated. Results indicated that (1) family environment factors explained a significant amount of variance in treatment refusal after controlling for demographic factors, (2) families of children with predominantly internalizing symptoms were at greater risk for refusing treatment than families of children with predominantly externalizing symptoms, and (3) lower level of family cohesion was an individual risk factor for refusing treatment. Incorporating an evaluation of family environment within SLMHS assessments may aid in the identification of areas wherein intervention may be beneficial in preventing treatment refusal.