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This chapter discusses some challenges to rural emergency psychiatric care. An appreciation of these challenges will help emergency medical and psychiatric providers collaboratively address them and prospectively develop effective, local paradigms of optimal emergency psychiatric care unique to their particular rural environment. The perception of mental illness by those in rural communities is an important clinical issue. Determining the level of suicidal or homicidal risks is an important component of any risk assessment in rural PES. One of the most important clinical issues in assessing behavioral health patients is the risk assessment. A paradigm of care should be developed and implemented in a public health approach to address rural emergency psychiatric care. Medical clearance continues to be a challenging issue in rural settings. To implement telepsychiatry, the participating physicians and institutions will need to implement consultation protocols, patient confidentiality protections, and develop mechanisms to streamline provider credentialing.