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The Sport Mental Health Assessment Tool-1 (SMHAT-1) screens for athlete mental health concerns, yet little is known about outcomes following positive screens.Objective This study examined the follow-up outcomes of Team USA athletes who exceeded thresholds on the SMHAT-1 questionnaire prior to the 2024 Paris Olympic and Paralympic Games.Methods A total of 847 SMHAT-1 assessments were completed (Paralympic, 26.7%; women, 52%). Questionnaires exceeding established thresholds were classified as a positive screen, which elicited follow-up by a Team USA mental health provider. During follow-up, mental health providers recorded follow-up outcomes using one of nine predefined outcomes. Outcomes were analysed for athletes with a single positive screen and for all unique positive screen combinations.Results 450 (53.1%) athletes had a positive screen. The most common outcomes were: ‘discussion without further action’ (31.8%), ‘athlete already connected to outside services’ (26.0%) and ‘inability to contact the athlete’ (20.4%). However, 43.1% of follow-ups required a service to be provided to the athlete.Conclusion While many positive screens did not require new clinical interventions, the proportion of athletes receiving follow-up care (43.1%) or were already in care (26.0%), underscores the need for diverse psychological resources to support elite athlete mental health. The inability to reach 20.4% of athletes following a positive screen suggests that alternative approaches for the deployment of the SMHAT-1 may be needed to allow for immediate clinician follow-up care. These findings support ongoing SMHAT-1 use and highlight the need for sufficient psychological services resources to meet athletes’ follow-up needs.